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This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and universities.

Chapter 4123-6 | Health Partnership Program

 
 
 
Rule
Rule 4123-6-01 | Definitions.
 

As used in this chapter:

(A) "Authorization" or "prior authorization" means:

Notification that a specific treatment, service, or equipment is medically necessary for the diagnosis or treatment of an allowed condition.

(B) "Bureau certified provider" means:

A provider who is approved by the bureau for participation in the health partnership program (HPP) pursuant to this chapter of Administrative Code.

(C) "Certification" or "recertification" means:

A process by which the bureau approves a provider or managed care organization (MCO) for participation in the HPP.

(D) "Credentialing" or "recredentialing" means:

A process by which the bureau validates or reviews the completed and signed application of a provider for certification or recertification.

(E) "Dispute resolution" means:

Procedures for the resolution of medical disputes prior to filing an appeal under section 4123.511 of the Revised Code.

(F) "Emergency" means:

Medical services that are required for the immediate diagnosis and treatment of a condition that, if not immediately diagnosed and treated, could lead to serious physical or mental disability or death, or that are immediately necessary to alleviate severe pain. Emergency treatment includes treatment delivered in response to symptoms that may or may not represent an actual emergency, but is necessary to determine whether an emergency exists.

(G) "Employee" means:

As used in the rules of this chapter, the term "employee" includes the terms "injured worker" and "claimant" and all employees of employers covered under HPP.

(H) "Health care provider" or "provider" means:

A physician or practitioner, or any person, firm, corporation, limited liability corporation, partnership, association, agency, institution, or other legal entity licensed, certified, or approved by a professional standard-setting body or by medicare or medicaid to provide medical services or supplies to an injured worker, including a qualified vocational rehabilitation provider.

(I) "Health partnership program" or "HPP" means:

The bureau of workers' compensation's comprehensive managed care program under the direction of the chief of medical services as provided in sections 4121.44 and 4121.441 of the Revised Code.

(J) "Hospital" means:

An institution that provides facilities for surgical and medical diagnosis and treatment of bed patients under the supervision of staff physicians and furnishes twenty-four hour-a-day care by registered nurses.

(1) For the purposes of this chapter relating to hospitals, "inpatient" means:

An injured worker is considered to be an inpatient when he or she has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. An injured worker is considered an inpatient if there is a formal order for admission from the physician. The determination of an inpatient stay is not based upon the number of hours involved. If it later develops during the uninterrupted stay that the injured worker is discharged, transferred to another inpatient unit within the hospital, transferred to another hospital, transferred to another state psychiatric facility or expires and does not actually use a bed overnight, the order from the attending physician addressing the type of encounter will define the status of the stay.

(2) For the purposes of this chapter relating to hospitals, "outpatient" means:

The injured worker is not receiving inpatient care, as "inpatient" is defined in paragraph (J)(1) of this rule, but receives outpatient services at a hospital. An outpatient encounter cannot exceed seventy-two hours of uninterrupted duration.

(K) "Injury" means:

For the purposes of the rules of this chapter of the Administrative Code only, an injury as defined in division (C) of section 4123.01 of the Revised Code or an occupational disease as defined in division (F) of section 4123.01 of the Revised Code.

(L) "Managed care organization" or "MCO" means:

A vendor as defined under section 4121.44 of the Revised Code who has contracted with the bureau to provide medical management and cost containment services as provided in sections 4121.44 and 4121.441 of the Revised Code. As used in these rules, a managed care organization is not a health care provider.

(M) "Medically necessary" means:

Services which are reasonably necessary for the diagnosis or treatment of disease, illness, and injury, and meet accepted guidelines of medical practice. A medically necessary service must be reasonably related to the illness or injury for which it is performed regarding type, intensity, and duration of service and setting of treatment.

(N) "Medication" means:

The same as drug as defined by division (E) of section 4729.01 of the Revised Code.

(O) "Non-bureau certified provider" means:

A provider who is not approved by the bureau for participation in the HPP, or whose certification has lapsed and has not been reinstated pursuant to rule 4123-6-02.4 of the Administrative Code.

(P) "Physician" means:

(1)

(a) A doctor of medicine, doctor of osteopathic medicine or surgery, or doctor of podiatric medicine who holds a current, valid certificate of licensure to practice medicine or surgery, osteopathic medicine or surgery, or podiatry under Chapter 4731. of the Revised Code;

(b) A doctor of chiropractic who holds a current, valid certificate of licensure to practice chiropractic under Chapter 4734. of the Revised Code;

(c) A doctor of mechanotherapy who holds a current, valid certificate of licensure to practice mechanotherapy under Chapter 4731. of the Revised Code and who was licensed prior to November 3, 1985;

(d) A psychologist who holds a current, valid certificate of licensure to practice psychology under Chapter 4732. of the Revised Code; or

(e) A dentist who holds a current, valid certificate of licensure to practice dentistry under Chapter 4715. of the Revised Code.

(2) A physician licensed pursuant to the equivalent law of another state shall qualify as a physician under this rule.

(Q) "Physician of record" or "attending physician" means:

Pursuant to Chapters 4121. and 4123. of the Revised Code, the authorized physician chosen by the employee to direct treatment.

(R) "Practitioner" means:

A physician, or a physical therapist, occupational therapist, optometrist, or any other person currently licensed and duly authorized to practice within his or her respective health care field.

(S) "Provider certification application and agreement" means:

A bureau form providers complete that requests background information and documentation necessary for certification and which, if completed and signed by the provider and approved by the bureau, constitutes a written, contractual agreement between the bureau and the provider.

(T) "Provider outcome measurement" means:

A medical management analysis tool used by the bureau or MCO which at a minimum, utilizes line item detail from a medical bill and employee specific information including, but not limited to, demographics, diagnosis allowances, return to work and remain at work statistics, and other data regarding treatment, to evaluate a health care provider on the basis of cost, utilization and treatment outcomes efficiency and compliance with bureau requirements.

(U) "Qualified health plan" or "QHP" means:

A health care plan sponsored by an employer or a group of employers which meets the standards for qualification under section 4121.442 of the Revised Code and is certified as a qualified health care plan with the bureau.

(V) "Recertification application and agreement" means:

A bureau form certified providers complete as part of the provider recertification process that requests background information and documentation necessary for recertification and which, if completed and signed by the provider and approved by the bureau, constitutes a written, contractual agreement between the bureau and the provider.

(W) "Remain at work services" means:

Services to support an injured worker in continued employment where the injured worker is experiencing difficulties performing a job as a result of conditions related to an allowed medical only claim.

(X) "Return to work services" means:

Services to support an injured worker in returning to employment where the injured worker is experiencing difficulty as a result of conditions related to an allowed lost time claim.

(Y) "Transitional work" means:

A work-site program that provides an individualized interim step in the recovery of an injured worker with job restrictions resulting from the allowed conditions in the claim. Developed in conjunction with the employer and the injured worker, or with others as needed, including, but not limited to the collective bargaining agent (where applicable), the physician of record, rehabilitation professionals, and the MCO, a transitional work program assists the injured worker in progressively performing the duties of a targeted job..

(Z) "Treatment guidelines" means:

Guidelines of medical practice, developed through consensus of practitioner representatives, that assist a practitioner and a patient in making decisions about appropriate health care for specific medical conditions.

(AA) "Urgent care facility" means:

A facility where ambulatory care is provided outside a hospital emergency department and is available on a walk in, non-appointment basis.

(BB) "Utilization review" means:

The assessment of an employee's medical care by the MCO. This assessment typically considers medical necessity, the appropriateness of the place of care, level of care, and the duration, frequency or quality of services provided in relation to the allowed condition being treated.

Last updated April 8, 2021 at 12:08 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 8/1/2025
Prior Effective Dates: 1/1/1999, 2/14/2005
Rule 4123-6-01.1 | Applicability of medical rules.
 

Unless specifically stated otherwise, the rules of this chapter governing payment of medical services and supplies shall apply to payments to health care providers in all claims for work related injuries or occupational diseases before the bureau, self-insuring employers, MCOs, QHPs, and the industrial commission.

However, nothing in these rules shall inhibit or diminish the commission's right to establish adjudicatory policy under Chapters 4121., 4123., 4127., and 4131. of the Revised Code, or otherwise prevent the full adjudication of claims properly before the commission or its hearing officers.

Last updated April 8, 2021 at 12:09 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 8/1/2025
Prior Effective Dates: 3/5/2010
Rule 4123-6-01.2 | Provisional treatment reimbursement approval -- pilot program.
 

Notwithstanding any provision to the contrary in any other rule of the bureau, the administrator may, for purposes of a pilot program, allow one or more managed care organizations to authorize medical treatment reimbursement requests for the first sixty days from the initial allowance of an identified at-risk claim for any conditions within the same body part or parts as the conditions initially allowed in the claim, and presumed to be causally related to the same industrial injury or occupational disease, without disclaimer, during such time as the conditions for which treatment reimbursement is authorized but which are not yet allowed are being considered for allowance or being adjudicated.

The operation of the pilot program authorized under this rule does not impair in any manner the right of an employer to appeal a claim, additional allowance, or medical treatment reimbursement determination under section 4123.511 of the Revised Code or rule 4123-6-16 of the Administrative Code.

The pilot program authorized under this rule is extended through December 31, 2022; provided, however, that the administrator may terminate the pilot program early at the administrator's discretion.

Last updated February 1, 2022 at 9:31 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4123.66
Amplifies: 4121.12, 4121.121, 4121.441
Five Year Review Date: 5/1/2025
Prior Effective Dates: 7/1/2019
Rule 4123-6-02 | Provider access to the HPP - generally.
 

(A) The bureau is authorized to certify a provider who wishes to participate in the HPP. The bureau is authorized to recertify a provider at least every one to three years. The bureau may, but is not required to, recertify providers on a staggered basis, in order of the provider's initial certification date or such other criteria as the bureau determines appropriate.

(B) A provider shall be certified or recertified by the bureau to treat injured workers if the provider is a direct service provider; meets and maintains credentialing criteria under rule 4123-6-02.2 of the Administrative Code; meets and maintains all other applicable criteria under the workers' compensation statutes and rules; and completes and signs a provider application and agreement or recertification application and agreement with the bureau.

Last updated April 8, 2021 at 12:09 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 8/1/2025
Prior Effective Dates: 1/5/1999, 1/1/2001
Rule 4123-6-02.2 | Provider access to the HPP - provider certification criteria.
 

(A) The bureau will establish minimum criteria for provider certification. Providers must meet all licensing, certification, or accreditation requirements necessary to provide services in Ohio. A provider licensed, certified, or accredited pursuant to the equivalent law of another state qualifies as a provider under this rule in that state. However, a provider is ineligible to participate in the health partnership program if:

(1) The state of Ohio has denied the provider's application for a professional license or the provider's professional license in Ohio is under revocation or suspension; or

(2) The provider's professional license is subject to disciplinary restrictions that affect the provider's ability to treat patients or that compromise patient care.

(B) The minimum criteria for a provider, where applicable based upon the type of provider, are as follows. The provider shall:

(1) Be currently licensed to practice, as applicable, without disciplinary restrictions that affect the provider's ability to treat patients or that compromise patient care.

(2) Meet other general certification criteria for the specific provider type, as provided in paragraph (C) of this rule.

(3) Not be currently excluded from participation in medicare or Ohio medicaid for cause.

(4) Not be currently ineligible to participate in the health partnership program due to the provider having been convicted of or pleaded guilty to a criminal offense as set forth in the appendix to this rule.

(5) Attest to and maintain professional malpractice and liability insurance, and provide proof of such coverage to BWC upon request.

(6) Provide documentation of the provider's malpractice history for the previous five years.

(7) Not have any outstanding provider overpayment or other indebtedness to the bureau which has been certified to the attorney general for collection.

(8) Maintain workers' compensation coverage to the extent required under Ohio law or the equivalent law of another state, as applicable, and provide proof of such coverage to BWC upon request.

(9) Not have been excluded or removed from participation in other health plans for cause.

(10) Not have lost hospital privileges for cause.

(C) The following minimum credentials apply to the providers listed below as provided in this rule.

(1) Adult day care facility: Ohio department of aging PASSPORT adult day care provider agreement.

(2) Alcohol and drug counseling clinic: certified by Ohio department of mental health and addiction services.

(3) Ambulance, ambulette, or air ambulance service: license from Ohio state board of emergency medical, fire, and transportation services if private; approved for medicare by the centers for medicare and medicaid services (CMS) if government/public.

(4) Ambulatory surgical center: license from Ohio department of health and approved for medicare by CMS.

(5) Anesthesiologist assistant: license from Ohio state medical board.

(6) Athletic trainer: license from Ohio occupational therapy, physical therapy, and athletic trainers board.

(7) Audiologist: license from Ohio state speech and hearing professionals board.

(8) Certified nurse practitioner: license from Ohio board of nursing and certified by American nurses credentialing center or other certifying agency approved by the Ohio board of nursing.

(9) Certified registered nurse anesthetist (CRNA): license from Ohio board of nursing and certified by national council on certification of nurse anesthetists or other certifying agency approved by the Ohio board of nursing.

(10) Certified shoe retailer: certified or accredited by American board for certification in orthotics, prosthetics and pedorthics or board of certification/accreditation.

(11) Chiropractic physician (D.C.): license from Ohio state chiropractic board.

(12) Clinical nurse specialist: license from Ohio board of nursing and certified by American nurses credentialing center or other certifying agency approved by the Ohio board of nursing.

(13) Comprehensive pain management services program: (free standing) commission on accreditation of rehabilitation facilities CARF accreditation; (hospital based) CARF or joint commission accreditation.

(14) Dentist: license from Ohio state dental board.

(15) Dialysis center: license from Ohio department of health and approved for medicare by CMS or a deeming organization approved by CMS.

(16) Durable medical equipment supplier (excludes orthotics, prosthetics and pedorthics): approved for medicare by CMS and state of Ohio board of pharmacy home medical equipment certificate of registration.

(17) Employment specialist:

(a)

(i) Certification for American board of vocational experts (ABVE), certified rehabilitation counselor (CRC), certified case manager (CCM), certified employment support professional (CESP), certification for individual placement and support (CIPS), global career development facilitator (GCDF), associate certified coach (ACC), professional certified coach (PCC), master certified coach (MCC), certified disability management specialist (CDMS), or CARF accreditation for employment and community services in job development or employment supports; or

(ii) Evidence of completion of three or more courses, seminars or workshops prior to application for certification, totaling a minimum of eighty hours and approved by the bureau or by an entity offering a certification referenced in paragraph (C)(17)(a)(i) of this rule, in at least two of the following domain areas: job development, job placement, and career and lifestyle development; vocational consultation and services for employers; professional roles and practices, ethics, and utilization of community resources; or

(iii) Evidence of bureau reimbursement to the provider for job placement, job development, job seeking skills training, job club, and/or job coaching services to injured workers for dates of service beginning not less than eighteen months prior to April 1, 2014. However, if the provider has been certified pursuant to this provision and the provider's certification subsequently lapses, the provider must thereafter meet the criteria of paragraph (B)(17)(a)(i) or (B)(17)(a)(ii) of this rule for certification or recertification.

(b) Employment specialists certified pursuant to paragraph (C)(17)(a)(ii) or (C)(17)(a)(iii) of this rule must complete thirty hours of continuing education, including three hours of ethics, every three years to maintain certification under this rule.

(18) Ergonomist: certification for certified professional ergonomist (CPE), certified human factors professional (CHFP), associate ergonomics professional (AEP), associate human factors professional (AHFP), certified ergonomics associate (CEA), certified safety professional (CSP) with "ergonomics specialist" designation, certified industrial ergonomist (CIE), certified industrial hygienist (CIH), assistive technology practitioner (ATP), or rehabilitation engineering technologist (RET).

(19) Hearing aid dealer: license from Ohio state speech and hearing professionals board.

(20) Home health agency: license from Ohio department of health, and approved for medicare by CMS or a deeming organization approved by CMS.

(21) Hospice: license from Ohio department of health, and approved for medicare by CMS.

(22) Hospital: license from Ohio department of health no later than September 30, 2024, and approved for medicare by CMS or a deeming organization approved by CMS, or obtained CARF accreditation for rehabilitation hospitals. The following facility types are eligible to be credentialed and certified as hospitals: short-term general and specialty hospitals; long-term care hospitals; rehabilitation hospitals; and psychiatric hospitals; hospital (provider) based urgent care facilities or clinics as designated on the hospital's medicare cost report.

(23) Independent diagnostic testing facility (IDTF): approved for medicare by CMS.

(24) Laboratory: valid clinical laboratory improvement amendments (CLIA) certificate.

(25) Licensed professional clinical counselor (LPCC) or licensed professional counselor (LPC): license from Ohio counselor, social worker, and marriage and family therapist board.

(26) Licensed social worker (LSW) or licensed independent social worker (LISW): license from Ohio counselor, social worker, and marriage and family therapist board.

(27) Massage therapist: license from Ohio state medical board.

(28) Non-physician acupuncturist: license to practice acupuncture or certificate to practice as an oriental medicine practitioner from Ohio state medical board.

(29) Nursing home: license from Ohio department of health or approved for medicare by CMS.

(30) Ocularist: license from Ohio state vision professionals board.

(31) Occupational rehabilitation-comprehensive programs (work hardening): CARF accreditation.

(32) Occupational therapist: license from Ohio occupational therapy, physical therapy, and athletic trainers board.

(33) Optician: license from Ohio state vision professionals board.

(34) Optometrist: license from Ohio state vision professionals board.

(35) Orthotist, prosthetist or pedorthist: license from Ohio occupational therapy, physical therapy, and athletic trainers board.

(36) Physical therapist: license from Ohio occupational therapy, physical therapy, and athletic trainers board.

(37) Physician (M.D. or D.O.): license from Ohio state medical board.

(38) Physician assistant: certified by national commission on certification of physician assistants and license from Ohio state medical board.

(39) Podiatric physician (D.P.M.): license from Ohio state medical board.

(40) Psychologist: license from Ohio state board of psychology.

(41) Radiology services (free-standing) registration from the Ohio department of health and approved for medicare by CMS or a deeming organization approved by CMS.

(42) Residential care/assisted living facility: license from Ohio department of health.

(43) Sleep laboratory: certified by the American academy of sleep medicine and approved for medicare by CMS or a deeming organization approved by CMS.

(44) Speech-language pathologist: license from Ohio state speech and hearing professionals board.

(45) Traumatic brain injury (TBI) program: CARF accreditation for brain injury services (acute or post-acute).

(46) Urgent care facility (free standing): approved for medicare by CMS.

(47) Vocational rehabilitation case managers: certification for ABVE, occupational health nursing (COHN(S)), CRC, CDMS, certified vocational evaluator (CVE), certified rehabilitation nurse (CRRN), or CCM.

(48) Vocational rehabilitation case management interns:

(a) Vocational rehabilitation case management may be provided by a bureau-certified intern. An intern is a non-credentialed individual who provides vocational case management services and is supervised by a credentialed vocational case manager, as identified in paragraph (C)(47) of this rule.

(b) To become eligible for bureau certification and provide service as an intern, the intern must:

(i) Enroll with the bureau as an intern.

(ii) Qualify to take one of the examinations to become credentialed, as identified in paragraph (C)(47) of this rule.

(c) Bureau certification of vocational rehabilitation case management interns shall be for a period of four years.

(d) Vocational rehabilitation case management interns cannot be recertified for additional four-year periods.

View Appendix

Last updated April 15, 2024 at 8:31 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 5/1/2025
Prior Effective Dates: 2/16/1996, 3/29/2002, 7/14/2003, 9/12/2004, 2/1/2010, 12/11/2012, 2/15/2018
Rule 4123-6-02.3 | Provider access to the HPP - provider application and certification criteria.
 

(A) The bureau shall make available to each provider a provider certification application and agreement or recertification application and agreement, as applicable, which shall require the provider to furnish documentation as provided in rule 4123-6-02.2 of the Administrative Code.

(B) The provider application and agreement or recertification application and agreement shall require the provider to make statements that the provider is without impairments that would interfere with the provider's ability to practice or that would jeopardize a patient's health, and a statement that the application is without misrepresentation, misstatement, or omission of a relevant fact or other acts involving dishonesty, fraud, or deceit. The provider shall provide to the bureau any additional documentation requested, and shall permit the bureau to conduct a review of the provider's practice or facility. The provider shall notify the bureau within thirty days of any change in the provider's ownership as reported on the application and agreement, or status regarding any of the credentialing criteria of paragraph (B) or (C) of rule 4123-6-02.2 of the Administrative Code.

(C) The bureau shall review the application and agreement and all documentation submitted by the provider. The bureau may cross-check data with other governmental agencies or licensing bodies. The bureau may refer provider certification and malpractice issues to the bureau's stakeholders health care quality assurance advisory committee for review as provided under rule 4123-6-22 of the Administrative Code.

(D) By signing the provider application and agreement or recertification application and agreement, the provider agrees to, and the bureau may refuse to certify or recertify or may decertify a provider for failure to:

(1) Provide health services that are applicable to a work related injury, and not to substantially engage in the practice of experimental modalities of treatment.

(2) Acknowledge and treat injured workers in accordance with bureau recognized treatment guidelines.

(3) Acknowledge and treat injured workers in accordance with the vocational rehabilitation hierarchy.

(4) Provide adequate on-call coverage for patients.

(5) Utilize bureau certified providers when making referrals to other providers.

(6) Timely schedule and treat injured workers to facilitate a safe and prompt return to work.

(7) Release information from the national practitioner data bank or the federation of state licensing boards. The bureau may submit a report to the appropriate state licensing board or data bank as required in the event the provider is decertified.

(8) Practice in a managed care environment and adhere to MCO and bureau procedures and requirements concerning provider compliance, outcome measurement data, peer review, quality assurance, utilization review, bill submission, and dispute resolution.

(9) Adhere to the bureau's confidentiality and sensitive data requirements, and use information obtained from the bureau by means of electronic account access for the sole purpose of facilitating treatment and no other purpose, including but not limited to engaging in advertising or solicitation directed to injured workers.

(10) Maintain professionalism, integrity, and civility in the provision of services in the HPP, including in all written and oral communications with the bureau, the industrial commission, the MCO, injured workers, employers, and their representatives.

(11) Comply with the workers' compensation statutes and rules and the terms of the provider application and agreement or recertification application and agreement.

(E) Upon review and determination by the bureau that the provider has met bureau credentialing requirements, the bureau shall certify or recertify the provider as a bureau certified provider.

(F) The bureau may enter into an addendum to a physician's provider certification application and agreement or recertification application and agreement, offering appropriate performance incentives to enhance physician proficiency in patient care and navigation of the Ohio workers' compensation system, to physicians who agree to:

(1) Perform enhanced duties as the treatment team leader in the care of injured workers, as set forth in the addendum, and

(2) Enhanced provider outcome measurement.

Last updated April 8, 2021 at 12:09 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 8/1/2025
Prior Effective Dates: 2/16/1996, 1/1/2018
Rule 4123-6-02.4 | Provider access to the HPP - provider and recertification.
 

(A) The bureau shall initiate the recertification process by sending certified providers notice and a recertification application and agreement, which must be completed, signed and submitted to the bureau if the provider wishes to be considered for recertification.

(B) Except as otherwise provided in paragraph (E) of this rule, if the bureau receives a completed and signed recertification application and agreement from a provider, the provider's certification shall remain in effect until the bureau issues a final order approving or denying the provider's application for recertification.

(C) If the bureau does not receive a completed and signed recertification application and agreement from the provider within sixty days from the date of the notice sent in accordance with paragraph (A) of this rule, the bureau shall send a second notice to the provider stating that the provider has thirty days from the date of the second notice to complete, sign and submit the recertification application and agreement to the bureau if the provider wishes to be considered for recertification.

(D) If the bureau does not receive a completed and signed recertification application and agreement from the provider within thirty days from the date of the second notice sent in accordance with paragraph (C) of this rule, the provider's certification shall lapse. Such lapse of certification is not an adjudication order and is not subject to appeal pursuant to rule 4123-6-17 of the Administrative Code.

(E) If the bureau receives a completed and signed recertification application and agreement from a provider after the provider's certification has lapsed pursuant to paragraph (D) of this rule, the provider's certification shall remain lapsed until the bureau issues a final order approving or denying the provider's application for recertification.

(F) All recertification applications and agreements are subject to review as provided in rule 4123-6-02.3 of the Administrative Code.

Last updated April 8, 2021 at 12:10 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 8/1/2025
Prior Effective Dates: 3/29/2002, 11/13/2015
Rule 4123-6-02.5 | Provider access to the HPP - provider not certified.
 

(A) A provider not certified or recertified shall cure any defects in the provider application and agreement or recertification application and agreement within thirty days of notice by the bureau.

(B) The administrator of the bureau of workers' compensation, pursuant to rule 4123-6-17 of the Administrative Code, may refuse to certify or recertify or may decertify a provider where the provider has failed to comply with the workers' compensation statutes or rules, or the terms of the provider application and agreement or recertification application and agreement.

(C) Notwithstanding paragraph (B) of this rule, the administrator may immediately revoke or suspend the certification and terminate the enrollment of a provider other than a hospital, in accordance with section 4121.443 of the Revised Code.

(D) The administrator may impose disciplinary sanctions upon a provider where the provider has failed to comply with the workers' compensation statutes or rules governing providers or the terms of the provider application and agreement or recertification application and agreement. In imposing a disciplinary sanction against a provider the administrator may consider, but is not limited to, suspending all reimbursements to a provider.

Last updated April 8, 2021 at 12:10 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4121.443, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4121.443
Five Year Review Date: 8/1/2025
Prior Effective Dates: 2/14/2005, 2/1/2010
Rule 4123-6-02.6 | Provider access to the HPP -- selection by an MCO.
 

(A) The bureau shall maintain a public list of bureau certified providers. The bureau shall make the list of bureau certified providers available through the bureau's website.

(B) An MCO may, but is not required to, retain a panel of bureau certified providers. A bureau certified provider is eligible to participate on an MCO's provider panel. A bureau certified provider may participate in a single MCO panel or may participate in more than one MCO panel.

(C) A provider identified by an MCO for temporary privileges in its panel of providers that is not a bureau certified provider shall be assisted by the MCO in applying for bureau provider credentialing and certification.

(D) The bureau or MCO shall not discriminate against any category of health care provider when establishing categories of providers for participation in the HPP. However, neither the bureau nor an MCO is required to accept or retain any individual provider.

(E) The MCO shall include in its panel or its arrangements with providers a substantial number of the medical, professional, and pharmacy providers currently being utilized by employees. An MCO may limit the number of providers on its MCO provider panel or with whom they enter into arrangements, but must do so based upon objective data approved by the bureau, such as reasonable patient access, community needs, the potential number of employees the MCO is applying to service, and other performance criteria, without discrimination by provider type.

(F) A bureau certified provider must follow the medical management and return to work management approaches of the MCO medically managing an employee's claim, whether or not the provider is on the MCO's provider panel, or has an arrangement with the MCO. MCO guidelines may not be more restrictive for a non-panel provider than for an MCO panel provider.

Last updated April 8, 2021 at 12:10 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 8/1/2025
Prior Effective Dates: 11/13/2015
Rule 4123-6-02.7 | Provider access to the HPP - provider decertification procedures.
 

(A) Except as otherwise provided in paragraph (C) of this rule, the administrator of the bureau of workers' compensation will follow the procedures set forth in this rule to terminate the enrollment of and decertify a non-facility provider who has failed to comply with a workers' compensation statute or rule.

(1) If the bureau determines a provider has committed three or more reported violations of the same workers' compensation statute or rule in a six month period, or five or more reported violations of any workers' compensation statute or rule in a six month period, the bureau will serve written notice of the violations to the provider.

(2) If the bureau determines the provider has committed two or more subsequent reported violations of any workers' compensation statute or rule for which the provider previously received notice pursuant to paragraph (A)(1) of this rule, and the subsequent violations occurred any time within the six month period following the calendar month in which the provider received notice pursuant to paragraph (A)(1) of this rule, the bureau will serve written notice of the violations to the provider, which will include a thirty day period within which the provider must submit and implement a correction plan signed by the provider. The bureau will enter the correction plan into the provider's certification file and will document that the provider is "under correction plan" during the six month period following the calendar month in which the provider's thirty day implementation period provided above expires.

If the provider fails to submit a correction plan within the thirty day implementation period satisfactory to the bureau, which satisfaction shall not be unreasonably withheld, the bureau shall send the provider written notification of the failure by certified mail, which shall include a notice of proposed enrollment termination and decertification complying with rule 4123-6-17 of the Administrative Code.

(3) If the bureau determines the provider has committed two or more subsequent reported violations of the same workers' compensation statute or rule for which the provider previously received notice pursuant to paragraph (A)(2) of this rule and submitted a correction plan satisfactory to the bureau, and the subsequent violations occurred any time within the six month period following the calendar month in which the provider's thirty day implementation period provided in the notice sent pursuant to paragraph (A)(2) of this rule expires, the bureau will serve written notice of the violations to the provider, which will include a notice of proposed enrollment termination and decertification complying with rule 4123-6-17 of the Administrative Code.

(4) If the bureau determines a provider who has twice received written notice pursuant to paragraph (A)(1) of this rule for violation of the same workers' compensation statute or rule has committed a subsequent reported violation of the same workers' compensation statute or rule within three years of the date written notification was first sent to the provider by the bureau pursuant to paragraph (A) of this rule, the bureau will serve written notice of the violations to the provider, which will include a notice of proposed enrollment termination and decertification complying with rule 4123-6-17 of the Administrative Code.

(5) The bureau may, in its discretion, consider mitigating circumstances in its application of the procedures set forth in paragraphs (A)(1) to (A)(4) of this rule with regard to an individual provider. Mitigating circumstances may include, but are not limited to:

(a) The violations related to the provision of emergency treatment;

(b) At the time the violations occurred, the provider was not aware a workers' compensation claim was involved;

(c) The provider was initially bureau certified within six months prior to the violations;

(d) The violations were due to bureau or MCO error;

(e) The provider billed the bureau for goods or services in fewer than five workers' compensation claims in the twelve months prior to the violations;

(f) Other documented justification as deemed sufficient by the bureau.

(6) The bureau will serve all notices to the provider pursuant to this rule in accordance with section 119.05 of the Revised Code.

(B) Providers whose enrollment is terminated and who are decertified pursuant to paragraph (A)(2), (A)(3), or (A)(4) of this rule are eligible to apply for and be considered for recertification and reenrollment at any time after two years from the date of the final administrative or judicial order of enrollment termination and decertification.

(C) The procedures set forth in paragraphs (A)(1) to (A)(6) of this rule do not apply to, and the administrator may proceed directly to enrollment termination and/or decertification of a provider for, the following:

(1) Violation of the minimum provider certification criteria set forth in rule 4123-6-02.2 of the Administrative Code.

(2) Acts of misrepresentation, misstatement, or omission of a relevant fact or other acts involving dishonesty, fraud, or deceit on the provider's provider application and agreement or recertification application and agreement.

(3) Acts involving breach of the bureau's confidentiality and sensitive data requirements, including but not limited to failure to maintain the confidentiality of injured worker medical or claim information.

(4) Acts involving misuse of information obtained from the bureau by means of electronic account access for a purpose other than facilitating treatment, including but not limited to engaging in advertising or solicitation directed to injured workers.

(5) Acts involving advertising or solicitation directed to injured workers in violation of rule 4123-6-02.9 of the Administrative Code.

(6) Acts of intentional misrepresentation, misstatement, or omission of a relevant fact or other acts involving false, fraudulent, deceptive, or misleading information on reports, information, and/or documentation submitted by the provider, the provider's employees, or the provider's agents to the bureau, industrial commission, claimant, employer, or their representatives, MCO, QHP, or self-insuring employer in connection with a workers' compensation claim.

(7) Upon peer review recommendation of the bureau of workers' compensation stakeholders' health care quality assurance advisory committee (HCQAAC) pursuant to rule 4123-6-22 of the Administrative Code, the bureau of workers' compensation pharmacy and therapeutics (P&T) committee pursuant to rule 4123-6-21.2 of the Administrative Code, or other peer review committee established by the bureau.

(8) Revocation or suspension in accordance with section 4121.443 of the Revised Code.

Last updated April 15, 2024 at 8:31 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 8/1/2025
Prior Effective Dates: 2/1/2010, 10/1/2016
Rule 4123-6-02.8 | Provider requirement to notify of injury.
 

(A) HPP: Within one business day of initial treatment or initial visit of an injured worker, a provider must report the employee's injury or occupational disease in accordance with either paragraph (A)(1) or (A)(2) of this rule.

(1) A provider may report an injury to the MCO responsible for medical management of the employee's treatment. When reporting the injury to the MCO, the provider shall do so in accordance with procedures established by the bureau.

(2) A provider may report an injury to the bureau through the bureau's website pursuant to rule 4125-1-02 of the Administrative Code.

(B) QHP: Within one business day of initial treatment or initial visit of an injured worker, a provider must report the employee's injury or occupational disease to the QHP or employer.

(C) Self-insuring employer (non-QHP): Within one business day of initial treatment or initial visit of an injured worker, a provider must report the employee's injury or occupational disease to the self-insuring employer.

Last updated April 8, 2021 at 12:10 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 8/1/2025
Prior Effective Dates: 2/16/1996, 11/13/2015
Rule 4123-6-02.9 | Provider access to the HPP - provider marketing.
 

(A) No bureau certified or enrolled provider shall engage in any advertising or solicitation directed to injured workers which is false, fraudulent, deceptive, or misleading.

(B) No bureau certified or enrolled provider shall hire, arrange for, or allow any other individual or entity to engage in any advertising or solicitation directed to injured workers on behalf of the provider which is false, fraudulent, deceptive, or misleading.

(C) No bureau certified or enrolled provider shall pay, allow, or give, or offer to pay, allow, or give, any consideration, money, or other thing of value to an injured worker, or to any other person, firm, or corporation (including but not limited to free or discounted examinations, treatment, or other goods or services) as an inducement to or in return for the injured worker ordering or receiving from the provider any goods or services for which payment may be made by the bureau, MCO, QHP, or self-insuring employer under Chapter 4121., 4123., 4127., or 4131. of the Revised Code.

(D) A bureau certified provider that violates this rule may be subject to termination of enrollment, decertification, or disciplinary sanctions pursuant to the rules of this chapter of the Administrative Code.

Last updated April 8, 2021 at 12:10 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 8/1/2025
Prior Effective Dates: 3/29/2002
Rule 4123-6-02.21 | Provider access to the HPP - non-certified provider enrollment.
 

(A) The bureau may enroll non-certified providers eligible under rule 4123-6-06.2 or 4123-6-10 of the Administrative Code or division (N) of section 4121.44 of the Revised Code to receive reimbursement for goods and services provided to injured workers, and for this purpose may require such non-certified providers to complete and sign an enrollment application as the bureau deems appropriate, provided such non-certified providers meet the minimum qualifications for their provider category as set forth in paragraph (C) of rule 4123-6-02.2 of the Administrative Code. The provider shall notify the bureau within thirty days of any change in the provider's ownership as reported on the enrollment application.

(B) Persons or entities who do not fall within the provider categories set forth in paragraph (C) of rule 4123-6-02.2 of the Administrative Code are not eligible for certification as providers. The bureau may enroll such persons or entities to receive reimbursement for goods and services provided to injured workers, and for this purpose may require such persons or entities to complete and sign an enrollment application as the bureau deems appropriate.

(C) The certification of providers who fall within the provider categories set forth in paragraph (C) of rule 4123-6-02.2 of the Administrative Code shall lapse, and the provider shall be enrolled with the bureau only, if the provider has had no billing activity with the bureau for a period of eighteen months or longer while certified. If the provider submits a bill while the provider's certification is lapsed pursuant to this paragraph, the provider may apply for recertification. However, the provider's certification shall remain lapsed until the bureau issues a final order approving or denying the provider's application for recertification.

(D) The enrollment of a non-certified provider, person, or entity pursuant to paragraph (A), (B), or (C) of this rule shall expire if the non-certified provider, person, or entity has had no billing activity with the bureau for a period of eighteen months or longer while enrolled as a non-certified provider.

(E) Lapse of provider certification pursuant to paragraph (C) of this rule and expiration of provider certification or enrollment pursuant to paragraph (D) of this rule do not constitute an adjudication order and are not subject to appeal pursuant to rule 4123-6-17 of the Administrative Code.

Last updated April 8, 2021 at 12:11 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 8/1/2025
Prior Effective Dates: 4/1/2007
Rule 4123-6-02.22 | Provider access to the HPP - ambulatory surgical center arthroplasty center requirements.
 

(A) To be eligible for participation in the HPP as an ambulatory surgical center arthroplasty center, an ambulatory surgical center must:

(1) Be certified as an ambulatory surgical center under paragraph (C) of rule 4123-6-02.2 of the Administrative Code.

(2) Have a formal joint replacement program which has been in place for at least one year prior to the date of application, and have performed a minimum of ten arthroplasty procedures prior to the date of application.

(3) Have a physician credentialing criteria policy which includes, at a minimum:

(a) A statement confirming any surgeon performing the service for injured workers is board certified in a related surgery specialty;

(b) A statement confirming any surgeon performing this service for injured workers has performed the procedure at the facility within one year prior to the date of application;

(c) A statement confirming any surgeon performing the service for injured workers has admitting privileges at a hospital within thirty miles of the facility or otherwise closest hospital;

(d) The facility recredentials surgeons at regular intervals.

(4) Have a patient selection criteria policy for injured workers consistent with applicable standards of care which includes, at a minimum:

(a) The patient is American society of anesthesiologists (ASA) physical status I (normal healthy patient) or II (patients with mild systemic disease);

(b) The patient is under sixty-five years of age;

(c) The patient has a body mass index which is not likely to affect surgical outcome;

(d) The patient has no co-morbid conditions that would be likely to affect surgical outcome;

(e) The patient has one or more individuals to assist with immediate post-surgical recovery care (home support).

(5) Report quality data measures to the centers for medicare and medicaid services (CMS) under the ambulatory surgical center quality reporting (ASCQR) program.

(6) Have an established protocol for tracking and reporting the following Ohio association of ambulatory surgery center (OAASC) quality data measures:

(a) Number of extended stays past midnight;

(b) Number of unexpected complications;

(i) Vomiting which does not respond to treatment;

(ii) Severe pain not responding to treatment;

(iii) Excessive bleeding necessitating a return to surgery or transfer;

(iv) Cardiac or respiratory arrest;

(c) Number of other incidents in the following areas:

(i) Medication errors;

(ii) Medical device errors;

(iii) Unintentional retained foreign body;

(d) Post discharge complications;

(i) Infections (thirty days post-operative; implants up to one year);

(ii) Emergency room visit within forty-eight hours for related issue;

(7) List on its application the specific procedure(s) it is requesting bureau certification to perform and receive reimbursement for under rule 4123-6-37.3 of the Administrative Code as an ambulatory surgical center arthroplasty center.

(B) The bureau is authorized to recredential and recertify a facility to participate in the HPP as an ambulatory surgical center arthroplasty center in accordance with rule 4123-6-02 of the Administrative Code.

(C) The administrator may decertify, or refuse to certify or recertify the facility as an ambulatory surgical center arthroplasty center, in accordance with rule 4123-6-17 of the Administrative Code and Chapter 119. of the Revised Code:

(1) If the facility has failed to meet or maintain any of the criteria for bureau certification as an ambulatory surgical center arthroplasty center set forth in paragraph (A) of this rule;

(2) Upon the recommendation of the bureau of workers' compensation stakeholders' health care quality assurance advisory committee (HCQAAC) or other peer review committee established by the bureau that injured worker safety would be compromised by the continued participation of the facility as an ambulatory surgical center arthroplasty center in the HPP; or

(3) As otherwise provided by this chapter of the Administrative Code.

Last updated April 15, 2024 at 8:31 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 8/1/2025
Prior Effective Dates: 5/1/2016
Rule 4123-6-02.51 | Provider access to the HPP -- Denial of provider, entity or MCO enrollment/certification based on criminal conviction or civil action.
 

(A) The administrator may refuse to certify or recertify, or may decertify from participation in the HPP, any MCO that:

(1) Is owned, directly or indirectly, by an individual or entity that has a felony conviction in any jurisdiction, a conviction under a federal controlled substance act, a misdemeanor conviction for an act involving dishonesty, fraud, or misrepresentation, a conviction for a misdemeanor committed in the course of practice, or a felony or misdemeanor conviction involving dishonesty, fraud, or misrepresentation related to any compensation or benefits payable under Chapter 4121., 4123., 4127., or 4131. of the Revised Code.

(2) Has one or more owners, shareholders, members, partners, managing employees, officers or directors, who have a conviction as described in paragraph (A)(1) of this rule; and including any MCO that is no longer so described because of a transfer of ownership or interest to an immediate family member or a member of the person's household in anticipation of or following a conviction as described in paragraph (A)(1) of this rule.

(3) Is owned directly, or indirectly, by an individual or entity who has engaged in specific conduct which demonstrates financial irresponsibility. Such conduct shall include, but not be limited to:

(a) Specific examples of insolvency of businesses owned or controlled by the individual or entity;

(b) Specific examples of failures to pay debts or judgments;

(c) Specific examples of activity which has defrauded any person, entity or organization, regardless of whether such activity has resulted in criminal prosecution;

(d) Any finding of fraud in a civil or administrative proceeding related to any compensation or benefits payable under Chapter 4121., 4123., 4127., or 4131. of the Revised Code or the equivalent laws of another state.

(B) The administrator may refuse to enroll, certify or recertify, or may terminate enrollment or decertify from participation in the HPP, any provider or entity that:

(1) Is owned, directly or indirectly, by an individual or entity that has been convicted of or pleaded guilty to a criminal offense as set forth in the appendix to rule 4123-6-02.2 of the Administrative Code. The provider or entity is ineligible for enrollment, certification, or recertification for the same period of ineligibility provided in the appendix to rule 4123-6-02.2 of the Administrative Code for the criminal offense.

(2) Has one or more owners, shareholders, members, partners, managing employees, officers or directors who have a conviction or plea of guilty to a criminal offense as set forth in the appendix to rule 4123-6-02.2 of the Administrative Code. The provider or entity is ineligible for enrollment, certification, or recertification for the same period of ineligibility provided in the appendix to rule 4123-6-02.2 of the Administrative Code for the criminal offense.

(3) It is owned directly, or indirectly, by an individual or entity who has engaged in specific conduct which demonstrates financial irresponsibility as described in paragraph (A)(3) of this rule.

(C) For the purposes of paragraphs (A) and (B) of this rule:

(1) "Entity" means any sole proprietorship, partnership, corporation, professional association, limited liability company or any other business organization doing business in this or any other state.

(2) "Immediate family member" means a person's spouse; natural or adoptive parent; child or sibling, stepparent, stepchild, stepbrother or stepsister; father-, mother-, daughter-, son-, brother- or sister-in-law; grandparent or grandchild; or spouse of a grandparent or grandchild.

(3) "Managing employee" means an individual (including a general manager, office manager, business manager, administrator or director) who exercises operational or managerial control over the provider, entity or MCO or part thereof, or directly or indirectly conducts the day-to-day operations of the provider, entity or MCO or part thereof, or is involved in the billing functions of the provider, entity or MCO or part thereof.

(4) "Member of household" means, with respect to a person, any individual with whom they are sharing a common abode.

(5) "Owned directly or indirectly" means having an interest that includes ownership, as an individual or through any other entity or entities, of five percent or more in the provider, entity or MCO at issue.

(D) Notwithstanding and in addition to the provisions set forth in this rule, pursuant to division (C)(1) of section 4121.444 of the Revised Code the administrator may terminate any agreement between the bureau and a person or a health care provider or managed care organization or its owner and cease reimbursement to, decertify and terminate the enrollment of that person, provider, organization, or owner for services rendered if any of the following apply:

(1) The person, health care provider, managed care organization, or its owner, or an officer, authorized agent, associate, manager, or employee of a person, provider, or organization is convicted of or pleads guilty to a violation of sections 2913.48 or 2923.31 to 2923.36 of the Revised Code or any other criminal offense related to the delivery of or billing for health care benefits.

(2) There exists an entry of judgment against the person, health care provider, managed care organization, or its owner, or an officer, authorized agent, associate, manager, or employee of a person, provider, or organization and proof of the specific intent of the person, health care provider, managed care organization, or owner to defraud, in a civil action brought pursuant to section 4121.444 of the Revised Code.

(3) There exists an entry of judgment against the person, health care provider, managed care organization, or its owner, or an officer, authorized agent, associate, manager, or employee of a person, provider, or organization in a civil action brought pursuant to sections 2923.31 to 2923.36 of the Revised Code.

(E) No person, health care provider, or managed care organization that has had its agreement with and reimbursement from the bureau terminated by the administrator pursuant to division (C)(1) of section 4121.444 of the Revised Code, or an owner, officer, authorized agent, associate, manager, or employee of that person, health care provider, or managed care organization shall do either of the following:

(1) Directly provide services to any other bureau provider or have an ownership interest, as an individual or through any other entity or entities, of five percent or more in a provider of services that furnishes services to any other bureau provider;

(2) Arrange for, render, or order services for claimants during the period that the agreement of the person, health care provider, managed care organization, or its owner is terminated as described in division (C)(1) of section 4121.444 of the Revised Code;

(F) The administrator shall not terminate the agreement or reimbursement if the person, health care provider, managed care organization, or owner demonstrates that the person, provider, organization, or owner did not directly or indirectly sanction the action of the authorized agent, associate, manager, or employee that resulted in the conviction, plea of guilty, or entry of judgment as described in division (C)(1) of section 4121.444 of the Revised Code.

(G) Nothing in division (C) of section 4121.444 of the Revised Code prohibits an owner, officer, authorized agent, associate, manager, or employee of a person, health care provider, or managed care organization from entering into an agreement with the bureau if the provider, organization, owner, officer, authorized agent, associate, manager, or employee demonstrates absence of knowledge of the action of the person, health care provider, or managed care organization with which that individual or organization was formerly associated that resulted in a conviction, plea of guilty, or entry of judgment as described in division (C)(1) of section 4121.444 of the Revised Code.

(H) Actions taken by the administrator pursuant to this rule shall be subject to rule 4123-6-17 of the Administrative Code.

Last updated August 30, 2023 at 1:42 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4121.444, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4121.444
Five Year Review Date: 8/1/2025
Prior Effective Dates: 9/1/2013
Rule 4123-6-03.2 | MCO participation in the HPP -- MCO application for certification or recertification.
 

(A) Upon request, the bureau shall send the MCO an application for certification which the MCO may complete and submit to the bureau.

(B) The application submitted to the bureau by the MCO shall include a list of bureau certified providers in its provider panel and/or bureau certified providers with which the MCO has arrangements.

(C) Regardless of whether the MCO elects to retain a provider panel or enters into provider arrangements, the application submitted to the bureau by the MCO shall include the following:

(1) A description of the MCO's health care provider panel or provider arrangements, including a substantial number of the medical, health care professional and pharmacy providers currently being utilized by injured workers. The provider panel or provider arrangements shall cover the geographic area in which the MCO plans to compete, and may include out-of-state providers.

(2) A description of how the MCO's provider panel or provider arrangements will provide timely, geographically convenient access to a full range of medical services and supplies for injured workers, including access to specialized services.

(3) A description of the MCO's process and methodology for credentialing providers in the MCO's provider panel, if applicable, and the MCO's process and methodology for assisting non-bureau certified providers in the MCO's provider panel or with which the MCO has provider arrangements in applying for bureau provider credentialing and certification.

(4) A description of the MCO's process and methodology for payment of providers in the MCO's provider panel or under a provider arrangement.

(5) A description of the MCO's policies and procedures for sanctioning and terminating providers in the MCO's panel, if applicable, and a description of the MCO's methodology to notify the bureau, employers and employees of any changes in the MCO's provider panel or provider arrangements.

(6) A description of the MCO's methodology for distributing provider panel and provider arrangement directories and directory updates to employers and employees.

(D) The application for certification submitted to the bureau by the MCO shall include, at a minimum, the following information and provisions:

(1) A statement that the application is without misrepresentation, misstatement, or omission of a relevant fact or other representations involving dishonesty, fraud, or deceit.

(2) A description of the geographic area of the state of Ohio for which the MCO wishes to be certified by the bureau. The minimum geographic area is a county. The bureau shall certify MCO participation on a county basis. The MCO may apply for coverage in more than one county or statewide.

(3) A description of the MCO that includes, but is not limited to, a profile that includes a disclosure statement regarding the MCO's organizational structure, including subsidiary, parent and affiliate relationships, together with historical and current data. The MCO must identify its principals; provide the MCO's date of incorporation or formation of partnership, or limited liability company, or business trust; provide any trade names or fictitious names the MCO is, or has been, doing business under; provide the number of years the MCO has operated in Ohio; identify other states in which the MCO is doing business or has done business; provide a table of organization with the number of employees; and identify any banking relationships, including all account information with any financial institutions.

(4) A description of the MCO's business continuity plan.

(5) A description of the bureau approved treatment guidelines used by the MCO, including a description of how the MCO shall implement the treatment guidelines.

(6) A description of the MCO's utilization review process.

(7) A description of the MCO's quality assurance/improvement standards program and process, including the use of satisfaction surveys.

(8) A description of the MCO's medical dispute resolution process that meets the requirements of rule 4123-6-16 of the Administrative Code.

(9) A description of the MCO's administrative and bill payment grievance processes.

(10) A description of the MCO's information system platforms, capabilities and capacities; a description of the MCO's system for reporting necessary data elements, including but not limited to those required for performance measurements; and the MCO's measures in place to ensure data security, including back-up systems.

(11) A description of the MCO's medical case management policies and procedures.

(12) A description of the MCO's policies and procedures regarding the protection of confidential and sensitive records.

(13) A description of the MCO's policies and procedures regarding retention of information.

(14) A description of the MCO's provider relations and education program.

(15) A description of the MCO's employer and employee relations and education program, including but not limited to a description of methodologies to be used to explain options available to injured workers, including treatment by non-network providers and the dispute resolution process.

(16) A description of the MCO's provider bill payment processes including, but not limited to, clinical editing software (including review criteria, process and methodology).

(17) Attestation of intent to obtain and maintain insurance coverage as required by the MCO contract, with proof of such coverage to be submitted to the bureau prior to execution of the contract, and current workers' compensation coverage.

(18) Attestation of intent to obtain and maintain professional accreditations as required by the MCO contract, with proof of such accreditations to be submitted to the bureau prior to execution of the contract.

(19) A description of any and all individuals and entities the MCO is affiliated with (including, but not limited to, a subcontractor or subcontractee, vendor or vendee, joint venture or other arrangement), and a copy of the MCO's contract or agreement with each individual or entity. For purposes of this rule, "affiliated with the MCO" shall have the same meaning as defined in paragraph (B) of rule 4123-6-03.9 of the Administrative Code.

(20) Other descriptions and requirements as contained in divisions (F)(1) to (F)(10) of section 4121.44 of the Revised Code.

(E) For MCO recertification, prior to the expiration of an MCO's certification, the bureau shall send the certified MCO an application for recertification, which must be completed and returned to the bureau. The MCO must be able to provide proof of delivery of the completed application to the bureau upon request. The application for recertification may be amended from time to time at the bureau's discretion.

(F) The bureau shall review the application for certification or recertification submitted by the MCO. The bureau reserves the right to cross-check data with other governmental agencies or licensing or accrediting bodies.

(G) During the bureau's review of the application for certification or recertification, the MCO shall provide to the bureau any additional documentation requested and shall permit the bureau, upon request and with reasonable notice given, to conduct an onsite review of the MCO.

(H) An MCO may cure any defects in its application for certification or recertification within thirty days of notice by the bureau of such defect in its application.

(I) The bureau may require that the application be accompanied by an application fee, which shall not exceed the amount sufficient to cover the cost of processing the application.

(J) The bureau shall hold as confidential and proprietary information contained in an MCO's application for certification or recertification, and other information furnished to the bureau by an MCO for purposes of obtaining certification or to comply with performance and auditing requirements established by the administrator, in accordance with divisions (H)(1) and (H)(2) of section 4121.44 of the Revised Code.

(K) The bureau shall not accept or approve any application for certification or recertification in which the MCO proposes to subcontract or outsource medical case management services, other than as part of the MCO's business continuity plan as described in paragraph (D)(4) of this rule and approved by the bureau. However, an MCO may subcontract onsite or out-of-state medical case management services with the prior approval of the bureau, provided such services are conducted under the supervision of the MCO.

Last updated February 1, 2022 at 9:30 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 41, 4121.44, 4121.441
Five Year Review Date: 2/1/2027
Prior Effective Dates: 2/16/1996
Rule 4123-6-03.4 | MCO participation in the HPP - MCO certification.
 

(A) Upon review by and satisfactory to the bureau that the managed care organization has met bureau certification standards, the bureau shall certify an MCO as eligible to contract with the bureau to provide medical management and cost containment services for injured workers and employers.

(B) MCO certification by the bureau shall be for a period of two years.

(C) The bureau may certify any number of MCOs for each county or statewide. Upon approval by the bureau, an MCO may expand its coverage area after the first year of certification and every year thereafter.

(D) The bureau shall maintain a current list of all bureau certified MCOs. The list shall include the name and address of each MCO and the counties in which the MCO is certified.

(E) An MCO may apply to the bureau for recertification beyond the first two years of certification.

Last updated April 8, 2021 at 12:11 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 8/1/2025
Rule 4123-6-03.7 | MCO participation in the HPP - bureau's authority to decertify, to refuse to certify or recertify an MCO.
 

(A) Should the administrator determine that sufficient evidence exists that an MCO has failed to maintain any of the requirements set forth in division (F) of section 4121.44 of the Revised Code, or to reasonably comply with or to perform in accordance with the terms of a contract between the bureau and the MCO entered into pursuant to division (B)(4) of section 4121.44 of the Revised Code, or has violated a rule adopted under section 4121.441 of the Revised Code, the administrator has the authority to decertify, or refuse to certify or recertify an MCO, in accordance with rule 4123-6-17 of the Administrative Code and Chapter 119. of the Revised Code.

(B) Upon a final order of the administrator to decertify, or refuse to recertify an MCO, employees and employers shall not receive services from such MCO pursuant to the HPP.

(C) Upon a final order of the administrator to decertify or refuse to recertify an MCO, any obligation of a provider to provide services under the HPP pursuant to a contract or agreement with such MCO shall be null and void.

Last updated May 31, 2023 at 9:50 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 8/1/2025
Prior Effective Dates: 6/9/2014
Rule 4123-6-03.9 | MCO participation in the HPP - MCO disclosure of relationship.
 

(A) If an MCO is affiliated with another individual, corporation, or entity that has had or contemplates activities of any nature with the Ohio workers' compensation system including but not limited to third party administrators, medical or vocational rehabilitation providers, professional employer organizations, and/or transitional work developers:

(1) To the extent such relationship creates or presents either the opportunity for a conflict of interest or preferential treatment or the appearance of a conflict of interest or preferential treatment for the managed care organization and/or the other individual, corporation, or entity, the MCO shall provide to the bureau a written description of the resolution of such opportunity for or the appearance of a conflict of interest satisfactory to the bureau; and shall disclose the potential conflict of interest and its resolution to the employers and injured workers assigned to the MCO.

(2) The MCO and the other affiliated corporation or entity shall implement complete separation of functions, offices, systems, and staff. Complete separation of staff shall include, but not be limited to, medical and vocational rehabilitation case management staff and marketing staff.

(B) For purposes of this rule, an individual, corporation, or entity is "affiliated with an MCO" when it:

(1) Owns, is owned by, or is under common ownership with an MCO, directly or indirectly through one or more intermediaries;

(2) Controls, is controlled by, or is under common control with an MCO, directly or indirectly through one or more intermediaries;

(3) Has a contractual or other business arrangement with an MCO;

(4) Has one or more owners, shareholders, partners, members, officers, directors or other persons who exercise operational or managerial control in common with the MCO.

Last updated May 31, 2023 at 9:50 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 8/1/2025
Prior Effective Dates: 2/16/1996, 10/26/2000
Rule 4123-6-03.10 | Conflict of interest.
 

No individual who is an officer or employee of an MCO shall represent a claimant or employer in any matter before the industrial commission, the bureau of workers' compensation, or a court of competent jurisdiction.

Last updated May 31, 2023 at 9:50 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4123.05
Amplifies: 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 8/1/2025
Prior Effective Dates: 1/1/2001
Rule 4123-6-04.3 | MCO scope of services - MCO medical management and claims management assistance.
 

(A) The MCO, in conjunction with the employer, injured worker, attending physician, and the bureau claims personnel assigned to the claim, shall provide medical management and cost containment services that facilitate the provision of high-quality, cost-effective medical care focused on minimizing the physical, emotional, and financial impact of a work related injury or illness and as appropriate, promotes a safe and timely return to work.

(B) The MCO shall educate employees and employers regarding access to and use of medical services for work related injuries or illnesses, and assist 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.

(D) The MCO shall review all bills submitted to it for payment by a provider consistent with the MCO's previous treatment reimbursement determination regarding the service billed, the MCO's utilization standards, the criteria set forth in rule 4123-6-25 of the Administrative Code, applicable industry standards, and the requirements of the MCO contract. The MCO shall have in place and operating a grievance hearing procedure allowing a provider, employer, or injured worker to grieve a disputed bill payment.

(E) The MCO shall refer a medical treatment reimbursement request in an inactive claim to the bureau, with the MCO's recommendation, for a determination of both the causal relationship between the original injury and the current incident precipitating the treatment request and the necessity and appropriateness of the requested treatment as provided in rule 4123-3-15 of the Administrative Code.

(F) An MCO shall provide medical management and return to work management services in a claim, as long as the employer remains assigned to the MCO, regardless of the date of injury of the claim. In cases where an injured worker has multiple claims with different employers, each claim remains with the associated employer and is managed by that employer's current MCO.

Last updated April 8, 2021 at 12:11 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 8/1/2025
Prior Effective Dates: 11/1/2004, 11/13/2015
Rule 4123-6-04.5 | MCO scope of services - bureau claims management.
 

(A) Upon receipt of notification of a workers' compensation claim, the bureau shall assign a claim number and shall notify the injured worker, employer and MCO of that claim number. The bureau shall determine the compensability of the claim and the allowed conditions of the claim pursuant to the provisions of section 4123.511 of the Revised Code. The bureau will notify all parties and the MCO of the allowed conditions in the claim.

(B) Upon referral from an MCO of a medical treatment reimbursement request in an inactive claim, after considering the MCO's recommendation the bureau will determine, as provided in rule 4123-3-15 of the Administrative Code, both the causal relationship between the original injury and the current incident precipitating a medical treatment reimbursement request and the necessity and appropriateness of the requested treatment. The bureau will notify all parties and the MCO of its determination.

The employer, injured worker, or representative may appeal the bureau's order to the industrial commission pursuant to section 4123.511 of the Revised Code.

(C) The bureau shall not make medical payments in a disallowed claim or for conditions not allowed in a claim until permitted to do so under the provisions of section 4123.511, 4123.512, or 4123.66 of the Revised Code or except as provided by the rules of this chapter or Chapter 4123-18 of the Administrative Code. The bureau shall notify all parties and the MCO when a claim or conditions are allowed or disallowed and indicate whether treatment rendered therefore may or may not be paid.

(D) During 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' compensation and may be the responsibility of the employee.

Last updated April 8, 2021 at 12:12 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.511, 4123.512, 4123.66
Five Year Review Date: 8/1/2025
Prior Effective Dates: 2/16/1996, 11/13/2015
Rule 4123-6-04.6 | Return to work assessment.
 

(A) The bureau may perform a return-to-work assessment of an injured worker who has eight or more days of lost time due to a work related injury and who has not returned to work within an acceptable timeframe as determined by the bureau.

(B) The assessment may include, but is not limited to, the medical case management goals, identification of barriers, return to work plan, medical stability and vocational status of the claim.

(C) All findings and conclusions of the assessment and all recommendations for addressing deficiencies shall be documented in writing to the MCO assigned to the claim. The assigned MCO shall have five business days from receipt of the bureau's findings to initiate or complete the recommended action steps identified by the bureau or propose alternative action steps acceptable to the bureau.

(D) If the assigned MCO does not carry out the recommended action steps or if the MCO fails to propose an acceptable alternative course of action to resolve the return-to-work barriers, the bureau may assume the medical and vocational rehabilitation management of the claim.

Last updated April 8, 2021 at 12:12 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.52
Five Year Review Date: 8/1/2025
Prior Effective Dates: 11/13/2015
Rule 4123-6-05.2 | Employer access to the HPP - employer enrollment and selection of MCO.
 

(A) An employer may select any bureau certified MCO that has contracted with the bureau, and has not been placed at capacity pursuant to the MCO contract, during an open enrollment period as provided in this rule. The bureau shall develop a process for verifying an employer's MCO selection.

(B) The bureau shall select an MCO for a state fund employer that fails to select an MCO, as necessary.

(C) If an MCO merges into or is acquired by another MCO, the bureau shall assign the employers formerly assigned to that MCO to the surviving MCO.

(D) If the administrator decertifies an MCO or terminates any agreement or contract between the bureau and an MCO, the bureau shall randomly assign the employers formerly assigned to the decertified or terminated MCO to all remaining, eligible MCOs.

(E) Selection of an MCO by an employer or selection by the bureau shall be until the next open enrollment period. At the bureau's discretion or upon the employer's request, the bureau may reassign an employer from the MCO if the bureau determines that the reassignment is in the best interest of both the employer and the MCO.

(F) Once the MCO has been selected by either the employer or the bureau, the employer shall notify all employees of the selection.

(G) The bureau shall establish an open enrollment period during which time an employer may change its selection of an MCO at least once every two years, but no more than once in a year. The administrator may waive the open enrollment period during a state of emergency or disaster declared by the governor of Ohio or the president of the United States. During an open enrollment period, an employer may:

(1) Select a new MCO; or

(2) Continue with the employer's current MCO. In such case, the employer is not required to notify the bureau during the open enrollment period.

(H) The bureau shall maintain and make available to employers electronically the list of all MCOs contracting with the bureau, and shall provide adequate notice to employers in writing of the deadline for new MCO selection.

(I) An MCO may not refuse to accept an employer that has selected it or has been assigned to it by the bureau, unless the MCO has placed itself at capacity pursuant to the MCO contract.

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 5/1/2025
Prior Effective Dates: 4/19/1996, 7/17/2000, 2/1/2010
Rule 4123-6-05.3 | Employer access to the HPP - certain solicitation practices by MCOs prohibited.
 

(A) An MCO, any individual, corporation, or entity affiliated with the MCO as defined in rule 4123-6-03.9 of the Administrative Code, or any other individual, corporation, or entity acting on behalf of an MCO or for the benefit of an MCO, shall not:

(1) Pay, allow, or give, or offer to pay, allow, or give, to any prospective employer or to any other person, firm, or corporation not an employee or agent of the MCO, either directly or indirectly, as an inducement to or in return for an employer's selection of the MCO, any rebate, premium, or kickback, or any special favor or advantage, or any other valuable consideration or inducement not provided for under Chapter 4123-6 of the Administrative Code.

(2) Pay, allow, or give, or offer to pay, allow, or give any commission, consideration, money, or other thing of value to any person, firm, or corporation not an employee or agent of the MCO for soliciting, negotiating, procuring, placing, writing, renewing, forwarding, or transmitting to the bureau an employer's selection of the MCO.

(B) Notwithstanding paragraph (A) of this rule, the MCO may reimburse to a trade or business association certain expenses in accordance with the following:

(1) The trade or business association meets the criteria for being a sponsoring organization for group rating pursuant to section 4123.29 of the Revised Code and rules 4123-17-61 to 4123-17-68 of the Administrative Code.

(2) The MCO may reimburse to the trade or business association only its actual and reasonable expenses incurred in educating its member employers on bureau and MCO medical management and cost containment services and related rules, policies, and processes.

(3) The MCO may reimburse to the trade or business association only its actual and reasonable expenses incurred in marketing the MCO to its member employers, subject to the limits set forth in paragraph (B)(4) of this rule.

(4) The reimbursement of a trade or business association's actual and reasonable expenses incurred in marketing the MCO to its member employers during a calendar year cannot exceed sixteen one-hundredths of one per cent of the premium of those employers that are members of the trade or business association and that have selected the MCO.

(5) The MCO and the trade or business association shall keep accurate records of all marketing and education services provided to its member employers for a period of four years from the date of performance of any such service and provide the bureau with access to such records within a reasonable time after a request for audit of such records by the bureau.

(C) Except as provided in paragraph (B) of this rule, no person, firm, or corporation not an employee or agent of the MCO shall knowingly receive any payment, commission, rebate, premium or kickback, or any other valuable consideration or thing of value described in paragraph (A) of this rule.

(D) For purposes of this rule, "affiliated with an MCO" has the same meaning as in paragraph (B) of rule 4123-6-03.9 of the Administrative Code.

(E) Agent of the MCO.

(1) For purposes of this rule, "agent" of the MCO means:

(a) An insurance agent or broker contracted by the MCO and licensed by the Ohio department of insurance pursuant to Title XXXIX of the Revised Code;

(b) A corporation or entity contracted by the MCO to conduct non-telephonic marketing that has not had and does not contemplate having activities of any nature with the Ohio workers' compensation system so as to create a conflict of interest or the appearance of a conflict of interest under rule 4123-6-03.9 of the Administrative Code;

(c) A telemarketer or telemarketing firm contracted by the MCO who has obtained a certificate of registration from the Ohio attorney general in accordance with Chapter 4719. of the Revised Code.

(2) "Agent" of the MCO does not include the following:

(a) A third party administrator, group rating sponsor, business or trade association;

(b) An individual, corporation, or entity affiliated with the MCO that has had or contemplates having activities with the Ohio workers' compensation system so as to create a conflict of interest or the appearance of a conflict of interest under rule 4123-6-03.9 of the Administrative Code.

Last updated April 15, 2024 at 8:32 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 8/1/2025
Prior Effective Dates: 10/26/2000, 4/1/2021
Rule 4123-6-05.4 | Employer access to the HPP; payment for referrals prohibited.
 

(A) An MCO shall not solicit, receive, or accept any payment, commission, consideration, money, or other thing of value, including, but not limited to any rebate, premium, or kickback, as an inducement to or in return for the MCO's referral of employers to any sponsoring organization or group for the purpose of participating in a group experience rating program authorized under section 4123.29 of the Revised Code and rules 4123-17-61 to 4123-17-68 of the Administrative Code.

(B) An MCO shall not solicit, receive, or accept any payment, commission, consideration, money, or other thing of value, including but not limited to any rebate, premium, or kickback, as an inducement to or in return for the MCO's referral of employers to any individual or entity for the provision of any goods or services.

(C) An MCO shall not solicit, receive, or accept any payment, commission, consideration, money, or other thing of value, including but not limited to any rebate, premium, or kickback, as an inducement to or in return for the MCO'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.

Last updated April 8, 2021 at 12:12 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 8/1/2025
Prior Effective Dates: 1/30/1998 (Emer.)
Rule 4123-6-06.2 | Employee access to the HPP - employee choice of provider.
 

(A) HPP.

(1) Except as provided in paragraph (A)(2) of this rule, an injured worker may seek medical care for a work related 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 immediate family member. The MCO, bureau, employer, and industrial commission shall not reimburse treatment to injured workers delivered, rendered or directly supervised by the injured worker or an immediate family member. "Immediate family member" shall have the same meaning as in paragraph (C)(2) of rule 4123-6-02.51 of the Administrative Code.

(3) At the time of an injury, the injured worker may seek medical care directly from a provider or may seek assistance from the MCO in selecting a provider. If the employee has not already sought medical care or selected a provider, the MCO may refer the employee to a provider or list of providers. The injured worker may, but is not required to, seek medical care from that provider or providers. The MCO shall not discriminate against any category of health care provider when referring the injured worker to a provider.

(4) If the injured worker seeks medical care from a provider, the injured worker shall inform the provider of the injured worker's MCO and/or employer. The provider shall then report the work related injury in accordance with rule 4123-6-02.8 of the Administrative Code.

(a) If the provider is a non-bureau certified provider, the MCO shall inform the provider that the care for the first visit will be compensated by the MCO if the claim and the treated conditions are subsequently allowed and that, unless otherwise permitted by paragraph (A)(5)(a) or (A)(5)(b) of this rule, no further treatment will be authorized.

(b) If the provider is a non-bureau certified provider, the provider shall inform the injured worker upon the initial or emergency treatment that the provider is not a participant in the HPP and that payment will not be made by the bureau, MCO, or employer for the cost of further treatment after the initial or emergency treatment

(5) An injured worker may continue treatment with a non-bureau certified provider under two circumstances:

(a) The MCO has determined that the treatment to be provided by the non-bureau certified provider is not reasonably available through a like bureau certified provider and has authorized the non-bureau certified provider to continue to provide the treatment, or

(b) The injured worker may continue to treat with the non-bureau certified provider, but at the injured worker's own expense without recourse against the bureau, MCO, or employer.

(6) Notwithstanding any other provision of this rule, if the injured worker's date of injury is prior to October 20, 1993 and the injured worker's physician of record is a non-bureau certified provider, the injured worker may continue treatment with that non-bureau certified provider. The employer's MCO shall manage the medical care and treatment and return to work services in the claim and shall manage medical payment for the provider. However, if the injured worker changes the physician of record for any reason, the injured worker shall select a bureau certified provider as physician of record. If the injured worker selects a physician of record who is a non-bureau certified provider, payment for the provider shall be governed by the provisions of this rule applicable to non-bureau certified providers.

(B) QHP.

(1) An injured worker of an employer that participates in a QHP has freedom of choice of providers within the QHP network of providers established by the employer's QHP. If the injured worker's date of injury is prior to the establishment of the employer's QHP, and the injured worker's physician of record is not a provider on the panel of the QHP when established, the injured worker may continue treatment with that physician of record. The physician of record shall be subject to and participate in the dispute resolution process as provided in rule 4123-6-69 of the Administrative Code. After the establishment of the QHP, the employer's QHP shall manage the medical care and treatment in the claim. If an injured worker changes from the physician of record who is not in the QHP for any reason, the injured worker shall select a QHP panel provider as the physician of record.

(2) An injured worker of an employer that participates in a QHP, who is dissatisfied with the health care services of a provider in the QHP, after written notice to the QHP, may request a change of providers and may select another provider within the QHP, or any bureau certified provider. An injured worker's request for change of provider does not require notification to the bureau, but shall contain the reasons for the request. The QHP shall approve written requests for a change of provider within the QHP, or to any bureau certified provider, within seven days of receipt

(3) Notwithstanding the provisions contained in paragraph (B)(2) of this rule, an injured worker who incurs a new medical condition, injury or claim requiring medical treatment, not related to a prior medical condition, injury or claim, shall first seek treatment from a provider on the panel of the injured worker's employer's QHP.

(4) Medical management of all injured workers' claims, whether medical services are provided within or without the QHP network of providers, shall be provided by the employer's QHP.

(5) A provider certified to participate in the HPP shall be eligible to participate in and to treat injured workers under the QHP system.

(C) Self-insuring employer (non-QHP).

(1) In claims with a date of injury on or after November 2, 1959, injured workers of self-insuring employers have free choice to select licensed physicians for treatment, as well as other medical services, including, but not limited to, hospital and nursing services. In claims with a date of injury prior to November 2, 1959, medical services furnished by the self-insuring employer must be utilized.

(2) Emergency treatment shall not constitute an exercise of free choice of physician.

(3) Once an injured worker of a self-insuring employer goes to a physician for treatment other than on an emergency basis, the injured worker is deemed to have made a choice of physician and the injured worker shall notify the employer of a change of physician.

(a) Change of physician requests shall be made to the self-insuring employer in writing, and shall include the name and address of the new physician and the proposed treatment.

(b) Self-insuring employers shall approve written requests for a change of physician within seven days of receipt.

Last updated February 1, 2022 at 9:31 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441,
Five Year Review Date: 2/1/2027
Prior Effective Dates: 2/16/1996, 11/13/2015
Rule 4123-6-07 | Services and supplies never covered.
 

The following services and supplies are never covered by, and shall not be authorized or reimbursed by, the bureau or MCO:

(A) Services and supplies that are never covered pursuant to other bureau statutes or rules.

(B) The following services and supplies, which are never considered to be durable medical equipment by the bureau:

(1) Home furniture including, but not limited to:

(a) Reclining chairs (except for the seat lift mechanism portion of a reclining chair);

(b) Non-hospital beds, (such as a water bed, adjust-a-sleep adjustable bed, craftmatic adjustable bed, electropedic adjustable bed, simmons beautyrest adjustable bed);

(c) Hospital bed mattresses larger than a standard (eighty inches long, thirty-six inches wide) size, except for bariatric hospital bed mattresses.

(2) Home exercise equipment, including but not limited to such equipment as treadmills and exercise bikes;

(3) Home whirlpools, including built-in whirlpools and pumps, portable hydrotherapy pools, jacuzzi tubs, portable saunas and spas, non-portable hot tubs or whirlpools, and therasaunas.

(4) Unsupervised physical reconditioning programs, except when the criteria have been met for an injured worker who is participating in a vocational rehabilitation or remain at work program.

(C) Self-administered sympathetic therapy/interferential therapy.

(D) Prescription smoking deterrent drugs outside an approved smoking cessation program, except when dispensed while the injured worker is admitted to a hospital during an approved inpatient admission or during the course of an outpatient visit in a hospital.

(E) Drug screening of injured workers performed by employers or performed in the emergency room at the time of injury at the request of the employer.

Last updated August 30, 2023 at 2:18 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.444
Five Year Review Date: 8/1/2025
Prior Effective Dates: 11/13/2015
Rule 4123-6-08 | Bureau fee schedule.
 

(A) Pursuant to division (A)(1)(h) of section 4121.441 of the Revised Code, the administrator of workers' compensation, with the advice and consent of the bureau of workers' compensation board of directors, 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 MCO, describing the method of payment, and make the MCO fee schedule available to the bureau as part of its application for certification. The bureau will maintain the MCO fee schedule as proprietary information.

View Appendix

Last updated May 1, 2024 at 9:04 AM

Supplemental Information

Authorized By: R.C. 4121.12, 4121.121, 4121.30, 4121.31, 4123.05
Amplifies: R.C. 4121.12, 4121.44, 4121.441, 4123.66
Five Year Review Date: 5/1/2025
Prior Effective Dates: 2/16/1996, 2/19/2009, 3/21/2011, 12/30/2013 (Emer.), 12/30/2014 (Emer.), 12/31/2015 (Emer.), 5/1/2016, 12/30/2016 (Emer.), 5/1/2018, 12/31/2018 (Emer.), 5/16/2020, 5/6/2021, 12/30/2021 (Emer.), 5/1/2023
Rule 4123-6-10 | Payment to providers.
 

(A) HPP.

(1) The MCO shall accumulate medical records and bills for services 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 panel or with whom the MCO has entered into an arrangement, other than a hospital, the bureau shall electronically transfer to the MCO for payment to the provider, in accordance with rule 4123-6-14 of the Administrative Code, either the lesser of the bureau fee schedule, the MCO contracted fee, or the charges billed by the provider for the allowed services rendered, or, if applicable under paragraph (A)(7) of this rule, the MCO negotiated fee.

(3) For a bureau certified provider who is not in the MCO's panel or with whom the MCO does not have an arrangement, other than a hospital, the bureau shall electronically transfer to the MCO for payment to the provider, in accordance with rule 4123-6-14 of the Administrative Code, either the lesser of the bureau fee schedule or the charges billed by the provider for the allowed services rendered, or, if applicable under paragraph (A)(7) of this rule, the MCO negotiated fee.

(4) For a non-bureau certified provider who is not in the MCO's panel or with whom the MCO does not have an arrangement, other than a hospital, the bureau shall electronically transfer to the MCO for payment to the provider for initial or emergency treatment, in accordance with rule 4123-6-14 of the Administrative Code, either the lesser of the bureau fee schedule or the charges billed by the provider for the allowed services rendered, or, if applicable under paragraph (A)(7) of this rule, the MCO negotiated fee.

(5) For a non-bureau certified provider who is not in the MCO's panel or with whom the MCO does not have an arrangement, other than a hospital, the bureau shall electronically transfer to the MCO for payment to the provider for subsequent treatment after the initial or emergency treatment, in accordance with rule 4123-6-14 of the Administrative Code, either the lesser of the bureau fee schedule or the charges billed by the provider for the allowed services rendered, or, if applicable under paragraph (A)(7) of this rule, the MCO negotiated fee, only under the following circumstances:

(a) Where the treatment provided by the non-bureau certified provider is not reasonably available through a like bureau certified provider and the MCO has authorized the treatment pursuant to rule 4123-6-06.2 of the Administrative Code, or

(b) Where the treatment provided by the non bureau certified provider is reasonably available through a like bureau certified provider, the non-bureau certified provider may only be reimbursed for the treatment if the provider becomes bureau certified. If the provider refuses or fails to become bureau certified, the treatment shall not be reimbursed.

(6) For hospital services, the bureau shall electronically transfer to the MCO for payment to the hospital, in accordance with rule 4123-6-14 of the Administrative Code, either the lesser of the applicable amount pursuant to rule 4123-6-37.1 (inpatient) or 4123-6-37.2 (outpatient) of the Administrative Code or the MCO contracted fee, or, if applicable under paragraph (A)(7) of this rule, the MCO negotiated fee.

(7) The MCO shall have authority to negotiate fees with providers, either by contract or on a case-by-case basis, in the following circumstances:

(a) As permitted under rule 4123-6-08 of the Administrative Code (including the appendix to the rule);

(b) As permitted under rule 4123-6-37.1, 4123-6-37.2 or 4123-6-37.3 of the Administrative Code;

(c) As permitted under rule 4123-18-09 of the Administrative Code;

(d) With non-bureau certified providers outside the state, where the treatment provided by the non-bureau certified provider is not reasonably available through a like bureau certified provider;

(e) With bureau certified providers and non-bureau certified providers within the state, where unusual circumstances justify payment above BWC's maximum allowable rate for the centers for medicare and medicaid services' healthcare common procedure coding system (HCPCS) level II and level III coded services/supplies, and such circumstances are documented and approved by the bureau.

(8) The bureau shall not pay for missed appointments or procedures. If the provider customarily charges for missed appointments or procedures, the provider shall inform the injured worker upon the initial or emergency treatment that the provider charges for missed appointments or procedures and that such charges are the responsibility of the injured worker. Bills must only contain descriptions of services that have been actually delivered, rendered, or directly supervised by the provider for the actual conditions treated. A provider shall not transmit to the MCO or bureau any bill containing false or misleading information that would cause a provider to receive payment for services that the provider is not entitled to receive.

(B) QHP.

(1) Within each QHP, all payments shall be in accordance with consistent billing and payment policies and practices established by the QHP and consistent with the provisions contained in paragraph (K)(5) of rule 4123-19-03 of the Administrative Code.

(2) With the exception that no financial arrangement between an employer or QHP and a provider shall incentivize a reduction in the quality of medical care received by an injured worker, an employer or QHP may pay a QHP panel provider a rate that is the same, is above or, if negotiated with the provider in accordance with rule 4123-6-46 of the Administrative Code, is below the rates set forth in the applicable provider fee schedule rules developed by the bureau. Nothing in the rules pertaining to the QHP system shall be construed to inhibit employers or QHPs and providers in their efforts to privately negotiate a payment rate.

(3) An employer or QHP shall pay a bureau certified non-QHP panel provider other than a hospital the lesser of the bureau fee schedule or the charges billed by the provider for the allowed services rendered, unless an alternate payment arrangement is negotiated between an employer or QHP and the provider in accordance with rule 4123-6-46 of the Administrative Code.

(4) An employer or QHP shall pay a bureau certified non-QHP panel hospital the applicable amount under rule 4123-6-37.1 (inpatient) or 4123-6-37.2 (outpatient) of the Administrative Code, unless an alternate payment arrangement is negotiated between an employer or QHP and the provider in accordance with rule 4123-6-46 of the Administrative Code.

(5) Employers' financial arrangements with company-based providers remain intact and services provided by company based providers need not be billed separately through QHP arrangements.

(6) An employer in the QHP system shall authorize and pay for initial or emergency medical treatment for an injury or occupational disease that is an allowed claim or condition provided by a non-bureau certified provider as follows:

(a) The employer shall pay a non-bureau certified provider only for initial or emergency treatment of an injured worker for a workers' compensation injury, unless the QHP specifically authorizes further treatment. A non-bureau certified provider shall inform the injured worker that the provider is not a participant in the QHP and that the injured worker may be responsible for the cost of further treatment after the initial or emergency treatment, unless payment for further treatment is specifically authorized by the QHP. The injured worker may continue to obtain treatment from the non-bureau certified provider, but the payment for the treatment shall be the injured worker's sole responsibility, except as provided in this paragraph.

(b) An employer or QHP shall pay a non-bureau certified provider that provides initial or emergency medical treatment or further medical treatment that has been specifically authorized by the QHP, other than a hospital, the lesser of the bureau fee schedule or the charges billed by the provider for the allowed services rendered, unless an alternate payment arrangement is negotiated between an employer or QHP and the provider in accordance with rule 4123-6-46 of the Administrative Code.

(7) An employer or QHP shall pay a non-bureau certified hospital that provides initial or emergency medical treatment or further medical treatment that has been specifically authorized by the QHP the applicable amount under rule 4123-6-37.1 (inpatient) or 4123-6-37.2 (outpatient) of the Administrative Code, unless an alternate payment arrangement is negotiated between an employer or QHP and the provider in accordance with rule 4123-6-46 of the Administrative Code.

(8) The employer or QHP shall not pay for missed appointments or procedures. If the provider customarily charges for missed appointments or procedures, the provider shall inform the injured worker upon the initial or emergency treatment that the provider charges for missed appointments or procedures and that such charges are the responsibility of the injured worker. Bills must only contain descriptions of services that have been actually delivered, rendered, or directly supervised by the provider for the actual conditions treated. A provider shall not transmit to the employer or QHP any bill containing false or misleading information that would cause a provider to receive payment for services that the provider is not entitled to receive.

(C) Self-insuring employer (non-QHP).

(1) Payment for medical services and supplies by self-insuring employers shall be equal to or greater than the fee schedule established by the bureau in state fund claims, unless otherwise negotiated with the provider in accordance with rule 4123-6-46 of the Administrative Code. All payments by the self-insuring employer shall be consistent with the provisions contained in paragraph (K)(5) of rule 4123-19-03 of the Administrative Code.

(2) The self-insuring employer shall not pay for missed appointments or procedures. If the provider customarily charges for missed appointments or procedures, the provider shall inform the injured worker upon the initial or emergency treatment that the provider charges for missed appointments or procedures and that such charges are the responsibility of the injured worker. Bills must only contain descriptions of services that have been actually delivered, rendered, or directly supervised by the provider for the actual conditions treated. A provider shall not transmit to the self-insuring employer any bill containing false or misleading information that would cause a provider to receive payment for services that the provider is not entitled to receive.

(D) Provider duty to report overpayment. A provider that has identified an overpayment must report and return the overpayment to the bureau, QHP or self-insuring employer within sixty days of identifying the overpayment. Providers must exercise reasonable diligence to identify and quantify overpayments.

Last updated June 13, 2022 at 1:19 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 8/1/2025
Prior Effective Dates: 2/1/2010, 11/13/2015
Rule 4123-6-14 | MCO bill submission to bureau.
 

(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 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. Upon receipt of funds from the bureau, the MCO shall pay the provider within seven days or less. The MCO shall pay to providers at least the amount electronically transferred by the bureau to the MCO for reimbursement of provider services.

(C) A provider that bills an MCO for services in expectation of payment from the MCO is responsible for the accuracy of all billing data and information the provider transmits to the MCO. The MCO is responsible for the accuracy of translating billing data received from the provider and the accuracy of transmitting billing data to the bureau that results in payment to the MCO or to the provider.

Last updated April 8, 2021 at 12:16 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 8/1/2025
Prior Effective Dates: 1/15/1999, 2/1/2010
Rule 4123-6-14.1 | Records to be retained by MCO.
 

(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 commission and bureau of workers' compensation have continuing jurisdiction over the claim pursuant to section 4123.52 of the Revised Code.

(2) The MCO shall also create, maintain, and retain records documenting transactions with the injured worker, providers, and subcontractors that do not relate to a specific claim, including but not limited to monthly bank statements, monthly bank records (e.g., deposit slips), account reconciliations and all supporting documentation (e.g., monthly check registers, outstanding check lists, voided transactions), and general and subsidiary ledger accounting records for a period of seven years from the date of the transaction.

(B) The failure of an MCO to create, maintain, and retain such records shall be sufficient cause for the bureau to deny payment for goods or services, or for performance fees, or for declaring overpaid previous payments made to the MCO, and may be cause for decertification.

(C) As used in this rule, "records" includes, but is not limited to, "record" and "electronic record" as defined in rule 4125-1-02 of the Administrative Code.

Last updated August 30, 2023 at 2:18 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 8/1/2025
Rule 4123-6-15 | Confidentiality of records.
 

(A) Subject to sections 2317.02, 4123.27, and 4123.88 of the Revised Code, certain employer premium, payroll, and claim file information is confidential and exempt from the general open records laws of Ohio, as set forth in section 149.43 of the Revised Code.

(B) In the course of medical management in the HPP, some confidential information may be provided by the bureau to the MCO, and/or exchanged among the bureau, the MCO, the employer and its representative, the injured worker and the injured 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 receiving and/or exchanging confidential information for use in the HPP shall not use such confidential information for any use other than to perform duties required by the HPP, and shall prevent such information from further disclosure or use by unauthorized persons. MCOs shall not release any confidential information, other than in accordance with rule 4123-3-22 of the Administrative Code, to any third parties (including, but not limited to, parent, subsidiary, or affiliate companies, or subcontractors of the MCO) without the express prior written authorization of the bureau.

(D) MCOs shall comply with, and shall assist the bureau in complying with, all disclosure, notification or other requirements contained in sections 1347.12, 1349.19, 1349.191 and 1349.192 of the Revised Code, as may be applicable, in the event computerized data that includes personal information, obtained by the MCO for use in the HPP, is or reasonably is believed to have been accessed and acquired by an unauthorized person and the access and acquisition by the unauthorized person causes, or reasonably is believed will cause a material risk of identity theft or other fraud.

(E) MCOs shall comply with all electronic data security measures as may be required by Ohio law, Ohio department of administrative services or other state agency directive, executive order of the governor of Ohio, and/or the MCO contract.

Last updated August 30, 2023 at 2:18 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 149.43, 1347.12, 1347.19, 1347.191, 1347.192, 2317.02, 4121.12, 4121.121, 4121.44, 4121.441, 4123.27, 4123.88
Five Year Review Date: 8/1/2025
Prior Effective Dates: 2/1/2010, 11/13/2015
Rule 4123-6-16 | Alternative dispute resolution for HPP medical issues.
 

(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 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) Within fourteen days of receipt of an MCO decision, an injured worker, employer, or provider may dispute the decision in writing (on form C-11 or equivalent) to the MCO. The written medical dispute must contain, at a minimum, the following elements:

(1) Injured worker name.

(2) Injured worker claim number.

(3) Date of initial medical treatment reimbursement request in dispute.

(4) Specific issue(s) in dispute, including description, frequency/duration, beginning/ending dates, and type of treatment/service/body part.

(5) Name of party making written appeal request.

(6) Signature of party making written appeal request or the party's authorized representative.

Written medical disputes that do not contain the minimum elements set forth in this paragraph may be dismissed by the MCO or bureau.

(C) Upon receipt of a written medical dispute, the MCO will initiate the ADR process, which consists of one independent level of professional review ("peer review") as follows:

(1) If an individual health care provider eligible to be physician of record would be providing the services requested in the dispute, the peer review is to be conducted by an individual or individuals licensed pursuant to the same section of the Revised Code as the health care provider who would be providing the services requested.

(2) Notwithstanding paragraph (C)(1) of this rule, if the MCO has already obtained one or more peer reviews during previous disputes involving the same treatment, the MCO may obtain a different perspective review from a licensed physician who falls outside the peer review criteria set forth in paragraph (C)(1) of this rule.

(3) If an individual health care provider not eligible to be physician of record would be providing the services requested in the dispute, peer review is to be conducted by an individual or individuals eligible to be physician of record whose scope of practice includes the services requested.

(4) If the MCO receives a dispute where the requested treatment is the same as a previous treatment request for which the MCO conducted a peer review, and the previous treatment request was ultimately denied based on the peer review, the MCO may use the previous peer review as the peer review under this paragraph, provided the peer review was conducted within six months of the current request and there are no new or changed circumstances in the injured worker's condition documented in the claim file.

(5) The MCO will submit a copy of the peer review to the bureau, and the bureau will provide the parties to the claim access to the peer review electronically.

(D) If, upon consideration of additional evidence or after agreement with the party that submitted the written medical dispute, the MCO reverses the decision under dispute or otherwise resolves the dispute to the satisfaction of the party, the MCO may issue a new decision and dismiss the dispute.

(E) The MCO will complete the ADR process and submit its recommended ADR decision to the bureau electronically within twenty-one days of the MCO's receipt of the written medical dispute, unless the injured worker is scheduled for an independent medical examination under paragraph (I) of this rule.

(F) Within two business days after receipt of a recommended ADR decision from the MCO, the bureau will publish and mail to all parties a final order, which may be appealed to the industrial commission pursuant to section 4123.511 of the Revised Code. The provider and the MCO may not file an appeal of the bureau order.

(G) Notwithstanding paragraph (C) of this rule, the MCO may pend a written medical dispute under the following circumstances:

(1) If the MCO receives a written medical dispute involving a medical treatment reimbursement request that is the same as a previous treatment request for which the MCO conducted a peer review, and the previous treatment request is pending before the bureau or industrial commission, the MCO may pend the new dispute until the previous treatment request has been resolved. Once the previous treatment request has been resolved, the MCO will resume the ADR process.

(2) If the MCO receives a written medical dispute involving a medical treatment reimbursement request that is dependent upon the outcome of an additional condition request pending before the bureau or industrial commission, the MCO may pend the dispute until the earlier of the final administrative or judicial decision or the industrial commission staff hearing officer decision on the request for the additional condition, at which time the MCO will resume the ADR process.

(H) Notwithstanding paragraph (C) of this rule, an MCO may submit its recommended ADR decision to the bureau electronically without obtaining a peer review under the following circumstances:

(1) The MCO receives a written medical dispute involving a medical treatment reimbursement request relating to the delivery of medical services that have been approved by the MCO pursuant to standard treatment guidelines, pathways, or presumptive authorization guidelines.

(2) The MCO receives a written medical dispute involving a medical treatment reimbursement request clearly relating to the delivery of medical services for a condition that is not allowed in the claim, and the issue of the allowance of the additional condition is not pending before the bureau or industrial commission.

(I) Either the MCO or the bureau may schedule an independent medical examination (IME) of the injured worker to assist in the ADR process under this rule.

(1) An ADR IME will be limited to issues relating to medical treatment disputes, and will not include extent of disability issues. An ADR IME will not be conducted at the request of an employer and does not substitute for an examination permitted under section 4123.651 of the Revised Code.

(2) If an ADR IME is scheduled under this rule, the parties, and their representatives, if any, will be promptly notified as to the time and place of the examination, and the questions and information provided to the doctor. The injured worker will be reimbursed for travel expenses in accordance with rule 4123-6-40 of the Administrative Code.

(3) The scheduling of an ADR IME will toll the MCO's time frame for completing the ADR process, and in such cases the MCO will submit its recommended ADR decision to the bureau electronically within seven days after receipt of the independent medical examination report.

(4) If an injured worker refuses to attend an IME to assist in the ADR process, the MCO will refer the issue to the bureau, and the injured worker's right to benefits may be suspended during the period of refusal.

Last updated June 18, 2024 at 3:47 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 8/1/2025
Prior Effective Dates: 11/8/1999, 1/1/2001, 4/1/2007
Rule 4123-6-16.1 | HPP medical treatment guidelines.
 

In reviewing medical treatment reimbursement requests pursuant to rule 4123-6-16.2 of the Administrative Code and conducting independent reviews of medical disputes pursuant to rule 4123-6-16 of the Administrative Code, the MCO and the bureau shall refer to treatment guidelines adopted by the bureau. In the event of a conflict between these guidelines and any provision of this chapter of the Administrative Code, the provisions contained in the Administrative Code shall control.

Last updated August 14, 2024 at 10:39 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4123.05
Amplifies: 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 8/1/2025
Prior Effective Dates: 9/12/2004
Rule 4123-6-16.2 | Medical treatment reimbursement requests.
 

(A) Medical treatment reimbursement requests (on form C-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-physician practitioner types:

(a) Advanced practice nurses;

(b) Physician assistants;

(c) Physical therapists;

(d) Occupational therapists;

(e) Optometrists;

(f) Audiologists;

(g) Licensed independent social workers;

(h) Licensed professional clinical counselors;

(i) Licensed prosthetists.

(B) Medical treatment reimbursement requests are evaluated by the MCO using the following three-part test (all parts must be met to authorize treatment reimbursement):

(1) The requested services are reasonably related to the industrial injury (allowed conditions);

(2) The requested services are reasonably necessary for treatment of the industrial injury (allowed conditions);

(3) The costs of the services are medically reasonable.

(C) For informational purposes, the bureau may require the provider to include on the medical treatment reimbursement request 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 of the request, for the procedures or services being requested.

However, review of the request is directed to the treatment being requested, and is not to be construed as approving or denying payment for the specific codes listed by the provider.

(D) Medical treatment reimbursement requests in inactive claims are processed in accordance with rule 4123-3-15 of the Administrative Code.

(E) Medical treatment reimbursement requests submitted by a physical therapist or occupational therapist must be accompanied by a prescription as required in paragraph (B) of rule 4123-6-30 of the Administrative Code, and approval of such requests is valid for no longer than thirty days unless the approval specifies a longer period and such longer period is supported by the prescription.

(F) Medical treatment reimbursement requests submitted by a prosthetist must be accompanied by a prescription from the physician of record or other approved treating provider licensed to practice medicine or osteopathic medicine.

(G) Approval of all medical treatment reimbursement requests is valid for no longer than six months unless the approval specifies a longer period.

(H) The MCO may dismiss without prejudice medical treatment reimbursement requests under the following circumstances:

(1) The request has been submitted by a provider who is not enrolled with the bureau and who refuses to become enrolled, or who is enrolled but non-certified and is ineligible for payment as a non-certified provider under rule 4123-6-06.2 or 4123-6-10 of the Administrative Code or division (N) of section 4121.44 of the Revised Code.

(2) The request is not accompanied by supporting medical documentation that the submitting provider has examined the injured worker within thirty days prior to the request, or that the injured worker requested a visit with the provider, and such evidence is not provided to the MCO upon request (through form C-9A or equivalent).

(3) The request duplicates a previous request that has been denied in a final administrative or judicial determination where the new request is not accompanied by supporting medical documentation of new and changed circumstances impacting treatment, and such evidence is not provided to the MCO upon request (through form C-9A or equivalent).

(4) The underlying claim has been settled, and the dates of service requested are on or after the effective date of the settlement. If the request includes both dates of service on or after the effective date of the settlement and dates of services prior to the effective date of the settlement, the MCO may dismiss without prejudice only that portion of the request relating to dates of service on or after the effective date of the settlement.

(5) The underlying claim has been disallowed or dismissed in its entirety, or the only allowances in the underlying claim are for substantial aggravation of a pre-existing condition, and the conditions have been determined in a final administrative or judicial determination to be in a non-payable status.

(6) The services or supplies being requested are never covered by the bureau pursuant to other bureau statutes or rules.

(7) Unless otherwise provided in this chapter of the Administrative Code, the MCO has requested from the submitting provider (through form C-9A or equivalent) supporting medical documentation necessary to the MCO's evaluation and determination, and such documentation is not provided to the MCO.

(8) A fee bill for the service was not submitted to the bureau or commission within the applicable time frame as set forth in rule 4123-3-23 of the Administrative Code.

(I) If the MCO determines that any approved medical treatment reimbursement request is not medically indicated or necessary, is not producing the desired outcomes, or the injured worker is not responding, the MCO may notify the parties of its decision to discontinue payment of approved treatment that has not already been rendered.

This decision is subject to alternative dispute resolution pursuant to rule 4123-6-16 of the Administrative Code.

(J) Notwithstanding any other provision of this rule, the bureau may reserve the authority to authorize or prior authorize reimbursement for services including, but not limited to, return to work management services pursuant to paragraph (D) of rule 4123-6-04.6 of the Administrative Code, caregiver services, and home and vehicle modifications.

Last updated October 1, 2024 at 9:13 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 8/1/2025
Prior Effective Dates: 7/25/2011, 4/1/2021
Rule 4123-6-16.3 | Reimbursement of retroactive medical treatment reimbursement requests.
 

(A) Except as otherwise provided in paragraph (D) of this rule, medical treatment reimbursement requests submitted retroactively to the MCO responsible for 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, "just cause" includes, but is not limited to:

(1) The treatment requested was emergency treatment;

(2) The provider was not aware that services were for a workers' compensation claim;

(3) The provider was non-bureau certified and had no established relationship with the injured worker;

(4) The provider was initially bureau certified within six months prior to the treatment request;

(5) The treatment requested was for a pending claim allowance or additional allowance with the bureau or industrial commission;

(6) The treatment provided was within the bureau's presumptive authorization guidelines, or does not require prior authorization per the bureau's provider billing and reimbursement manual;

(7) The treatment request was submitted retroactively due to bureau or MCO error;

(8) Other documented justification as deemed sufficient by the bureau.

(C) Determinations that an approved medical treatment reimbursement request shall be reimbursed at seventy-five per cent of the applicable fee schedule amount pursuant to paragraph (A) of this rule shall be subject to the grievance hearing procedure for disputed bill payments provided by rule 4123-6-04.3 of the Administrative Code.

(D) Retroactive medical treatment reimbursement requests submitted within seven calendar days of the initiation of treatment or prior to the date of the physician of record or eligible treating provider's next encounter with the injured worker, whichever is earlier, shall not be subject to payment reduction under paragraph (A) of this rule.

Last updated August 14, 2024 at 10:39 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 8/1/2025
Prior Effective Dates: 11/13/2015
Rule 4123-6-17 | Bureau refusal to certify or recertify, action to decertify a provider or MCO - standards and procedures for adjudication hearings.
 

(A) The administrator of the bureau of workers' compensation may refuse to certify 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 provider, MCO, or QHP an opportunity for a hearing by serving written notice to the provider, MCO or QHP in accordance with Chapter 119. of the Revised Code. The notice will include a statement informing the provider, MCO, or QHP that if the bureau does not receive a request for a hearing within thirty days of the time of the service of the written notice, the administrator may proceed with an adjudication order concerning the provider, MCO, or QHP.

(D) If no timely request for a public hearing is made by the provider, MCO, or QHP, the administrator may issue an adjudication order concerning the provider, MCO, or QHP.

(E) If the provider, MCO, or QHP files a timely request for a hearing, the bureau will schedule the hearing in accordance with sections 119.07 and 119.09 of the Revised Code. The hearing will be held at the bureau central office in Columbus, but if requested by the provider, MCO, or QHP, the bureau may hold the hearing in the bureau office closest to the place of business of the provider, MCO, or QHP.

(F) Conduct of hearing.

(1) The hearing will be conducted in accordance with Chapter 119. of the Revised Code. The administrator may conduct the hearing personally or may delegate the hearing to a referee, who will be an attorney at law. The referee may be from the bureau's legal division or an attorney employed by the administrator especially for such purpose. The bureau has the burden of proof to establish, by a preponderance of the evidence, cause for suspending or revoking the certification of a provider, MCO, or QHP.

(G) Should the provider, MCO, or QHP be adversely affected by the order of the administrator, the provider, MCO, or QHP may file a notice of appeal of the decision in accordance with section 119.12 of the Revised Code.

(H) Any adjudicating order of the administrator to decertify, or to refuse to recertify a provider, MCO, or QHP shall include a clear indication of the beginning date of such action.

Last updated April 15, 2024 at 8:32 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 119.05, 119.07, 119.09, 119.092, 119.12, 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 8/1/2025
Prior Effective Dates: 2/1/2010, 11/13/2015, 4/1/2021
Rule 4123-6-18 | Data gathering and reporting.
 

(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 medical care, and effectiveness of medical care delivered by all components of the workers' compensation system.

(2) Compile data to support activities of the MCOs and to measure the outcomes and savings of the HPP.

(3) Publish and report compiled data on the measures of outcomes and savings of the HPP to the governor, the speaker of the house of representatives, and the president of the senate with the annual report prepared under division (F)(3) of section 4121.12 of the Revised Code.

(B) The administrator shall compile at least annually and make available electronically to each employer a report that summarizes the performance of each MCO.

Last updated April 8, 2021 at 12:18 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 8/1/2025
Prior Effective Dates: 2/1/2010
Rule 4123-6-19 | Remain at work services.
 

(A) The bureau shall take measures and make expenditures, as it deems necessary, to aid injured workers who have sustained compensable injuries or contracted occupational diseases to remain at work.

(B) Remain at work services.

(1) An injured worker is eligible to receive remain at work services when:

(a) The injury results in a medical only claim which is certified by the employer or is allowed pursuant to a bureau or industrial commission order or a lost time claim with eight or more days of lost time due to a work related injury which is certified by the employer or is allowed pursuant to a bureau or industrial commission order, but the injured worker is not receiving and has not been awarded temporary total compensation or salary continuation in the claim; and,

(b) It is documented by the employer, the injured worker, or the physician of record that the injured worker is experiencing problems that are work-related and result from the allowed conditions in the claim.

(2) Services provided shall be charged to the employer's risk.

(3) The MCO shall determine the need for remain at work services.

(4) Within five business days of completion of services, the MCO shall submit a final report to the bureau.

(5) The bureau may audit the MCO's utilization of remain at work services.

(C) Scope of remain at work services.

(1) Remain at work services may include ergonomic study, functional capacity evaluation, job analysis, physical therapy (on site), occupational therapy (on site), physical reconditioning, transitional work, gradual return to work, on the job training, short term training, job modification, tools and equipment, and remain at work case management.

(2) The bureau will not reimburse an employer for remain at work services that are provided by the employer (e.g., transitional work, on the job training, gradual return to work).

(3) Remain at work services shall cease upon the occurrence of any of the following:

(a) A bureau, industrial commission or court order subsequently disallowing the claim.

(b) The claim changes to a lost time claim with eight or more days of lost time due to a work related injury and the injured worker receives temporary total compensation or salary continuation in the claim.

(c) The effective date of lump sum settlement.

(4) A claim that changes to a lost time claim with eight or more days of lost time due to a work related injury may be referred for vocational rehabilitation services as provided under Chapter 4123-18 of the Administrative Code if the injured worker is receiving or has been awarded temporary total compensation or salary continuation in the claim.

Last updated May 31, 2023 at 9:59 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 8/1/2025
Prior Effective Dates: 2/14/2005
Rule 4123-6-20 | Obligation to submit medical documentation and reports.
 

(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's agents shall not submit or cause or allow to be submitted to the bureau, industrial commission, injured worker, employer, or their representatives, MCO, QHP, or self-insuring employer any report, information, anddocumentation containing false, fraudulent, deceptive, or misleading information.

(B) Physician's medical reports of work ability.

(1) Physicians treating injured workers shall complete, sign, and submit to the MCO a physician's report of work ability on form MEDCO-14 or equivalent upon every injured worker encounter, unless:

(a) The injured worker has been awarded compensation for permanent total disability;

(b) The injured worker returns to work without restrictions within seven days of the injury; or

(c) The injured worker is seeing the treating physician after the treating physician has submitted a MEDCO-14 or equivalent releasing the injured worker to return to the former position of employment without restrictions.

(2) The physician's report of work ability must include at a minimum the following:

(a) The date of the report;

(b) The date of the last examination;

(c) The "International Classification of Disease" diagnosis code(s) recognized in the claim for all conditions and all parts of the body being treated that are affecting the length of disability, including a primary diagnosis code, with a narrative description identifying the condition(s) and specific area(s) of the body being treated;

(d) Any reason(s) why recovery has been delayed;

(e) The date temporary total disability began;

(f) The current physical capabilities of the injured worker;

(g) An estimated or actual return to work date;

(h) An indication of need for vocational rehabilitation;

(i) Objective findings; and

(j) Clinical findings supporting the information in this rule.

(C) Treatment plan.

(1) Upon allowance of a claim by the bureau, industrial commission, or self-insuring employer, the physician of record and other providers treating the injured worker shall provide and continue to update a treatment plan to the MCO, QHP, or self-insuring employer according to the format or information requirements designated by the bureau. A treatment plan should include at least the following:

(a) Details of the frequency, duration, and expected outcomes of medical interventions, treatments, and procedures;

(b) The estimated return to work date; and

(c) Factors that are unrelated to the work-related condition, but are impacting recovery.

(2) Modifications should be made to the initial treatment plan as treatment is extended, changed, completed, added, deleted or canceled. The modification should describe the current prognosis for the injured worker, progress to date, and expected treatment outcomes.

(3) Treatment plans should be updated when significant changes occur in the claim that impact claims management. Changes include:

(a) Additional allowance;

(b) Re-activation;

(c) Authorization of expenditures from the surplus fund;

(d) Return to modified or alternative work;

(e) Maximum medical improvement;

(f) Rehabilitation;

(g) A new injury while receiving treatment in the claim.

(D) Supplemental reports or other bureau forms from the attending physician and other providers may be requested by the bureau, industrial commission, employer, MCO, QHP, or by the injured worker or representative. These reports shall be used to determine the appropriateness of a benefit, bill payment, or allowance.

(E) In accepting a workers' compensation case, a provider assumes the obligation to provide to the bureau, injured worker, employer, or their representatives, MCO, QHP, or self-insuring employer, upon written request or facsimile thereof and within five business days, all medical, psychological, psychiatric, or vocational documentation relating causally or historically to physical or mental injuries relevant to the claim required by the bureau, MCO, QHP, or self-insuring employer, and necessary for the injured worker to obtain medical services, benefits or compensation.

(F) Independent medical examinations.

(1) A provider performing an independent medical examination of a injured worker shall create, maintain, and retain sufficient records, papers, books, and documents in such form to fully substantiate the accuracy of the resulting report submitted 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's agents shall keep such records in accordance with rule 4123-6-45.1 of the Administrative Code, and such records shall be subject to audit pursuant to rule 4123-6-45 of the Administrative Code.

(2) A provider performing an independent medical examination of a injured worker shall keep confidential all information obtained in the performance of the independent medical examination, including but not limited to knowledge of the contents of confidential records of the bureau, industrial commission, injured worker, employer, or their representatives, MCO, QHP, or self-insuring employer. The provider, the provider's employees, and the provider's agents shall maintain the confidentiality of such records in accordance with all applicable state and federal statutes and rules, including but not limited to rules 4123-6-15 and 4123-6-72 of the Administrative Code.

Last updated April 8, 2021 at 12:18 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 8/1/2025
Prior Effective Dates: 1/1/2001, 11/13/2015
Rule 4123-6-20.1 | Charges for copies of medical reports.
 

(A) The purpose of this rule is to provide parties to a workers' compensation claim reasonable access to and reasonable charges for medical records necessary for the administration of the claim.

(B) Except 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 access to all filed medical records without charge through secure electronic access.

(2) Where the bureau has provided access to medical records electronically and a party requests copies of such medical records, the bureau may charge a fee for the copies in accordance with the Ohio public records laws.

(3) Where a provider has filed copies of medical records with the bureau or MCO and the bureau has provided access to such medical records electronically or the provider has filed copies of medical records with the self-insuring employer, if a party requests such medical records of the provider, the provider may charge a fee for the copies. The provider's fee shall not exceed the amount allowable under sections 3701.741 and 3701.742 of the Revised Code.

(C) As provided in division (B) of section 4123.651 of the Revised Code, a claimant shall promptly provide a current signed release of medical information, records, and reports relative to the issues necessary for the administration of the claim when requested by the employer. The employer shall immediately provide copies of all medical information, records, and reports to the bureau and to the claimant or the claimant's representative upon request.

Last updated April 8, 2021 at 12:18 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 149.43, 3701.741, 3701.742, 4113.23, 4121.12, 4121.121, 4121.44, 4121.441, 4123.651
Five Year Review Date: 8/1/2025
Prior Effective Dates: 11/13/2015
Rule 4123-6-21 | Payment for outpatient medication.
 

(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 necessary for treatment of the allowed conditions in a claim.

(B) Medication 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 enrolled but non-certified shall be denied except in the following situations:

(a) The prescription is written by a non-bureau certified provider during initial or emergency treatment of the injured worker if the injured worker's claim and treated conditions are subsequently allowed.

(b) The prescription is written by a non-bureau certified provider who is outside the state or within the state where no or an inadequate number of bureau certified providers exist and the MCO has determined that the treatment to be provided by the non-bureau certified provider is not reasonably available through a like bureau certified provider and has authorized the non-bureau certified provider to continue to provide the treatment.

(c) The prescription is written by a non-bureau certified provider for an injured worker with a date of injury prior to October 20, 1993, the provider was the injured worker's physician of record prior to October 20, 1993, and the injured worker has continued treatment with that non-bureau-certified provider.

(C) Drugs covered 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 from an enrolled pharmacy provider.

(D) The bureau may require prior authorization of certain drugs or therapeutic classes of drugs, drugs above a certain cost threshold, drugs submitted outside a certain time frame from the date of injury or the last prescription submitted. or drugs being prescribed for a condition or in a manner not approved by the FDA. The bureau will publish a list of all such drugs or therapeutic classes of drugs, cost thresholds, or time frames for which prior authorization is required.

(E) Prescriptions for compounded drug products:

(1) Prior authorization may be required for compounded sterile drug products.

(2) Compounded non-sterile prescriptions.

(a) Reimbursement for non-sterile compounded prescriptions will be denied, except when a commercially available formulary product becomes unavailable (listed on the "Food & Drug Administration Drug Shortages List," or "American Society of Health-System Pharmacists Drug Shortages List").

(b) Reimbursement for non-sterile compounded prescriptions shall only be considered upon the submission of both:

(i) A prior authorization request, and

(ii) A copy of the signed prescription that lists all active pharmaceutical ingredients. The prescription must comply with the Ohio state board of pharmacy requirements for a valid prescription set forth in rules 4729-5-13 and 4729-5-30 of the Administrative Code.

(c) Approval for reimbursement of non-sterile compounded prescriptions will be for an initial period of thirty days with subsequent approvals contingent upon commercial product availability. Not more than one prescription for a non-sterile compounded prescription will be approved for reimbursement in any thirty day period.

(F) Drugs which fall into one of the following categories may be approved and reimbursed by an MCO as part of a comprehensive treatment plan submitted by the physician of record or treating physician:

(1) Drugs for the treatment of obesity;

(2) Drugs for the treatment of infertility;

(3) Non-compounded parenteral drugs not intended for self-administration;

(4) Drugs used to aid in smoking cessation;

(5) Drugs dispensed to a injured worker while the injured worker is admitted to a hospital during an approved inpatient admission or during the course of an outpatient visit in a hospital.

(G) Payment for medications to pharmacy providers shall include both a product cost component and a dispensing fee component.

(1) Except as provided in this paragraph, product cost component shall be the lesser of the following: maximum allowable cost, if applicable, or the average wholesale price (AWP) of the commonly stocked package size minus fifteen per cent.

(a) For repackaged brand name medications, the product cost component shall be calculated using the AWP of the original labeler.

(b) For compounded prescriptions, the product cost component shall be limited to the lesser of the maximum allowable cost, if applicable, for each ingredient, or the AWP of the commonly stocked package size minus fifteen per cent for each ingredient.

(c) The maximum reimbursement for any one non-sterile compounded prescription will be one hundred dollars.

(2) The dispensing fee component for non-compounded prescriptions shall be three dollars and fifty cents. Only pharmacy providers are eligible to receive a dispensing fee.

(3) The dispensing fee component for non-sterile compounded prescriptions shall be eighteen dollars and seventy-five cents.

(4) The dispensing fee component for sterile compounded prescriptions shall be thirty-seven dollars and fifty cents.

(H) The pharmacy provider is required to bill medication at their usual and customary charge. The amount paid to the provider will be the lesser of the provider's usual and customary charge or the reimbursement allowed as determined by the bureau under paragraph (G) of this rule. The bureau shall not reimburse any third-party pharmacy biller that submits pharmacy bills on behalf of a pharmacy provider or that has purchased pharmacy bills from a pharmacy provider for subsequent submission to the bureau for payment. Pharmacy providers are required to submit for billing the NDC number of the stock bottle from which the dispensed medication is obtained. Drugs may be dispensed in unit dose packaging, but the NDC number of the closest comparable bulk package listed in the bureau or the bureau's pharmacy benefit manager's payment system must be used for billing purposes. The pharmacy provider shall:

(1) Include prescriber information within bills submitted electronically to the bureau or the bureau's pharmacy benefits manager for payment. The prescriber information must include the national provider identifier (NPI) or the drug enforcement administration (DEA) number;

(2) Not pay, allow, or give, or offer to pay, allow, or give, any consideration, money, or other thing of value to an injured worker, or to any other person, firm, or corporation (including but not limited to free or discounted medications or other goods or services) as an inducement to or in return for the injured worker ordering or receiving from the provider any medications or other goods or services for which payment may be made by the bureau, the bureau's pharmacy benefits manager, or MCO under Chapter 4121., 4123., 4127., or 4131. of the Revised Code;

(3) Comply with all applicable billing instructions contained in the bureau's provider billing and reimbursement manual in effect on the billed date(s) of service.

(I) The bureau may establish a maximum allowable cost for single source or multi-source medications which are pharmaceutically and therapeutically equivalent, that is, contain identical doses of the active ingredient and have the same biological effects as determined by the FDA and designated by an "A" code value in the FDA publication, "Approved Drug Products With Therapeutic Equivalence Evaluations" in effect on the billed date(s) of service. The methodology used to determine a maximum allowable cost for a qualified drug product shall be determined by the bureau. The bureau may choose to utilize the maximum allowable cost list of a vendor or develop its own maximum allowable cost list.

(J) Injured workers who request a brand name drug or whose physician specifies a brand name drug designated by "dispense as written" on the prescription for a medication for which pharmaceutically and therapeutically equivalent medication exist, as defined in paragraph (I) of this rule, shall be liable for the product cost difference between the AWP of the dispensed brand name drug minus fifteen percent and the established maximum allowable cost price of the drug product. However, the bureau may approve reimbursement of the dispensed brand name drug at the AWP of the drug minus fifteen per cent if the following circumstances are met:

(1) The injured worker has a documented, systemic allergic reaction as a result of taking the generic equivalent which is consistent with known symptoms or clinical findings of a medication allergy; or

(2) The injured worker has been prescribed, and has tried, another generic equivalent and the intended therapeutic benefit has not been achieved or an unacceptable adverse event has occurred.

(K) The following dispensing limitations may be adopted by the bureau:

(1) The bureau may publish supply limitations for drugs which represent the maximum number of days supply that may be dispensed at any one time for a single prescription.

(2) The bureau may publish maximum prescription quantities which represent the largest number of units per drug that may be dispensed at any one time for a single prescription.

(3) Requests submitted that exceed any published days supply limit or maximum quantity limit shall be denied. Denials may be overridden by the bureau in cases where medical necessity and appropriateness have been determined.

(4) Refills of drugs not scheduled by the DEA requested before eighty per cent of any published days supply limit has been utilized will be denied.

(5) Refills of drugs scheduled by the DEA requested before ninety per cent of any published days supply limit has been utilized will be denied.

(6) Denials may be overridden by the bureau for the following reasons with supporting documentation:

(a) The injured worker's pharmacy is submitting an early refill for a shortened days supply to support synchronizing the filling or refilling of the prescription in a manner that allows the dispensed drug to be obtained on the same date each month;

(b) The injured worker is traveling out of the country and will be unable to refill medications during that time;

(c) The injured worker's pharmacy will be closed for more than two days.

(d) An emergency or disaster, as defined in division (O) of section 4123.511 of the Revised Code, is declared by the governor of Ohio or the president of the United States.

(L) Except as otherwise provided in paragraph (F) of this rule, outpatient medications shall be billed to and reimbursed through the bureau's pharmacy benefits manager. Pharmacy providers must submit bills for medication by an on-line point-of-service authorization terminal or a host-to-host link with the bureau's pharmacy benefits manager's established bill processing system as a condition of provider enrollment or reimbursement. Submission by paper or by tape-to-tape will not be accepted by the bureau or the bureau's pharmacy benefits manager.

(M) A claimant may request outpatient medication reimbursement in accordance with rule 4123-6-26 of the Administrative Code using form C-17 or equivalent. Claimant reimbursement may be limited to the following situations:

(1) Claimants whose medication is not payable under division (I) of section 4123.511 of the Revised Code on the date of service, but later becomes payable;

(2) Emergency situations where an enrolled pharmacy provider is not available;

(3) Claimants who reside out of the country.

(N) A "pharmacy provider" designation and provider number can be obtained by a provider who meets all the following criteria:

(1) Has a valid "terminal distributor of dangerous drugs" as defined in section 4729.01 of the Revised Code if located within Ohio; or an equivalent state license if located outside of Ohio; and,

(2) Has a valid DEA number; and,

(3) Has a licensed registered pharmacist in full and actual charge of a pharmacy; and,

(4) Has the ability and agrees to submit bills at the point of service.

All state and federal laws and regulations relating to the practice of pharmacy and the dispensing of medication by a duly licensed pharmacist must be observed.

(O) The bureau may contract with a pharmacy benefit manager to perform drug utilization review and on-line bill processing, maintain a pharmacy provider network and prior authorization program for medications, and provide management reports. The bureau or its vendor may also contract rebate agreements with drug manufacturers. The bureau may utilize other services or established procedures of the pharmacy benefits manager which may enable the bureau to control costs and utilization and detect fraud.

(P) The bureau may identify circumstances under which it may consider reimbursement for pharmacist professional services (also known as cognitive services) when payment for such services results in a measurable, positive outcome. The bureau shall be responsible for developing the criteria which will be used to assess the compensability of billed pharmacist professional services. The bureau shall be responsible for developing the structure of the reporting of the measurable outcomes used to justify the payment of pharmacist professional services, which may include reimbursement for the dispensing fee component. The amount that could be reimbursed for pharmacist professional services shall be determined by the bureau.

(Q) The bureau shall retain a registered pharmacist licensed in the state of Ohio to act as the full-time pharmacy program director to assist the bureau in the review of drug bills. The pharmacy program director may assist the bureau in determining the appropriateness, eligibility, and reasonableness of compensation payments for drug services. The bureau may adopt a drug formulary with the recommendation of the bureau's pharmacy and therapeutics committee established by rule 4123-6-21.2 of the Administrative Code, and may consult with the committee on the development and ongoing annual review of the drug formulary and other issues regarding medications.

Last updated October 30, 2024 at 2:39 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31,4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44,4121.441, 4123.66
Five Year Review Date: 8/1/2025
Prior Effective Dates: 6/2/2017
Rule 4123-6-21.1 | Payment for outpatient medication by self-insuring employer.
 

(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 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 comprehensive treatment plan submitted by the physician of record or a treating physician when reasonably related to and medically necessary for treatment of the allowed conditions in the claim, provided that such approval and reimbursement shall not constitute the recognition of any additional conditions in the claim even if such drugs are used to treat conditions that have not been allowed in the claim.

(E) Payment for medications to pharmacy providers shall include both a product cost component and a dispensing fee component.

(1) Except as provided in this paragraph, product cost component shall be the lesser of the following: maximum allowable cost established under paragraph (N) of this rule, if applicable, or the average wholesale price (AWP) of the commonly stocked package size minus fifteen per cent.

(a) For repackaged brand name medications, the product cost component shall be calculated using the AWP of the original labeler.

(b) For compounded prescriptions, the product cost component shall be limited to the lesser of the the maximum allowable cost, if applicable, for each ingredient or the AWP of the commonly stocked package size minus fifteen per cent for each ingredient.

(c) The maximum product cost component reimbursement for any one non-sterile compounded prescription will be four hundred dollars.

(2) The dispensing fee component for non-compounded prescriptions shall be three dollars and fifty cents, unless the self-insuring employer has negotiated a payment rate with the pharmacy provider pursuant to rule 4123-6-46 of the Administrative Code. Only pharmacy providers are eligible to receive a dispensing fee.

(3) The dispensing fee component for non-sterile compounded prescriptions shall be eighteen dollars and seventy-five cents.

(4) The dispensing fee component for sterile compounded prescriptions shall be thirty-seven dollars and fifty cents.

(F) The pharmacy provider is required to bill medication at their usual and customary charge. The amount paid to the provider will be the lesser of the provider's usual and customary charge or the reimbursement allowed as determined in paragraph (E) of this rule, unless the self-insuring employer has negotiated a payment rate with the provider pursuant to rule 4123-6-46 of the Administrative Code. Pharmacy providers are required to submit for billing the national drug code (NDC) number of the stock bottle from which the dispensed medication is obtained. Drugs may be dispensed in unit dose packaging, but the NDC number of the closest comparable bulk package listed in the bureau or vendor payment system must be used for billing purposes.

(G) The pharmacy provider shall:

(1) Include prescriber information within bills submitted electronically to the self-insuring employer or its vendor for payment. The prescriber information must include the national provider identifier (NPI) or the drug enforcement administration (DEA) number;

(2) Not pay, allow, or give, or offer to pay, allow, or give, any consideration, money, or other thing of value to an injured worker, of to any other person, firm, or corporation (including but not limited to free or discounted medications or other goods or services) as an inducement to or in return for the injured worker ordering or receiving from the provider any medications or other goods or services for which payment may be made by the self-insuring employer or its vendor or QHP under Chapter 4121., 4123., 4127., or 4131. of the Revised Code;

(3) Comply with all applicable billing instructions contained in the bureau's provider billing and reimbursement manual in effect on the billed date(s) of service.

(H) Claimant reimbursement for medications shall be in accordance with rule 4123-6-26 of the Administrative Code and shall at least be equal to the bureau's established rate for the medication, unless the self-insuring employer has negotiated a payment rate with the pharmacy provider utilized by the claimant pursuant to rule 4123-6-46 of the Administrative Code, in which case the claimant reimbursement shall be at least the rate negotiated with the provider. Requests for reimbursement must be paid within thirty days of receipt of the request.

(I) Self-insuring employers must obtain a drug utilization review from a physician before terminating payment for current medications, as follows:

(1) Except as otherwise provided in paragraph (I)(7) of this rule, before terminating payment for current medications, the self-insuring employer shall notify all parties to the claim (including authorized representatives) and the prescribing physician, in writing, that a physician drug review is being performed, or has been performed, regarding the necessity and appropriateness of the continued use of current medications (by therapeutic drug class).

(2) The written notice shall inform all parties to the claim (including authorized representatives) and the prescribing physician that they have twenty-one days from receipt of the notice to provide additional information and/or medical documentation to justify the need for continued use of the medications (by therapeutic drug class).

(3) The self-insuring employer shall provide all medically related information regarding the medications to an independent physician reviewer for review and opinion as to the necessity or appropriateness of the medications. If the self-insuring employer has obtained an independent physician reviewer's report prior to sending the notice required by paragraph (I)(1) of this rule and subsequently receives additional information and/or medical documentation pursuant to paragraph (I)(2) of this rule, the self-insuring employer shall provide the additional information and/or medical documentation to the independent physician reviewer and obtain an addendum. The independent physician reviewer's report (and addendum, if applicable) shall address the medical rationale, necessity and appropriateness of the drug treatment in the control of symptoms associated with the allowed conditions in the claim.

(4) When the independent physician reviewer's report (and addendum, if applicable) indicates the drug treatment is not medically necessary or appropriate for treatment or in the control of symptoms associated with the allowed conditions in the claim, the self-insuring employer may terminate reimbursement for the medications (by therapeutic drug class) effective as of the date of receipt of the independent physician reviewer's report, or addendum if one is obtained, or in the case that a drug is in a therapeutic class that requires a "weaning-off" period, in accordance with the tapering schedules set forth in the appendix to rule 4123-6-21.5 of the Administrative Code or such other date as agreed to by the prescribing physician and self-insuring employer.

(5) In the event the self-insuring employer terminates reimbursement for the medications as set forth in paragraph (I)(4) of this rule, the self-insuring employer or its authorized representative shall provide all parties to the claim (including authorized representatives) and the prescribing physician with a copy of the independent physician reviewer's report (and addendum, if applicable) and the self-insuring employer shall notify the injured worker and the injured worker's representative in writing of its decision to terminate. The employer's notification to the injured worker and injured worker's representative shall indicate that the injured worker has the right to request a hearing before the industrial commission.

(6) In the event there is a dispute as to whether the drug treatment is medically necessary or appropriate for treatment of the symptoms associated with the allowed conditions in the claim, the disputed matter shall be adjudicated in accordance with paragraph (K)(5) of rule 4123-19-03 of the Administrative Code.

(7) The self-insuring employer may terminate current medications that have been removed from the bureau's outpatient medication formulary set forth in the appendix to rule 4123-6-21.3 of the Administrative Code without obtaining a physician drug review. However, the tapering schedules set forth in the appendix to rule 4123-6-21.5 of the Administrative Code would apply.

(J) Self-insuring employers may deny initial requests for a drug or therapeutic class of drugs as not being reasonably related to or medically necessary for the treatment of the allowed conditions in a claim.

(K) Self-insuring employers may contract with a pharmacy benefits manager. A self-insuring employer utilizing a pharmacy benefits manager may require pharmacy providers to submit bills for medication by an on-line point-of-service authorization terminal or a host-to-host link with the pharmacy benefits manager's established bill processing system as a condition of reimbursement, and may refuse submission by paper or by tape-to-tape. Self-insuring employers utilizing a pharmacy benefits manager may refuse to reimburse any third-party pharmacy biller that submits pharmacy bills on behalf of a pharmacy provider or that has purchased pharmacy bills from a pharmacy provider for subsequent submission to the self-insuring employer for payment.

(L) Self-insuring employers utilizing a pharmacy benefits manager may require prior authorization of drugs or therapeutic classes of drugs which appear on the bureau's published list of drugs or therapeutic classes of drugs for which prior authorization is required. Notwithstanding rule 4123-19-03 of the Administrative Code, the self-insuring employer shall approve or deny a prior authorization request within three business days of the request.

(M) Self-insuring employers utilizing a pharmacy benefits manager may apply the following dispensing limitations, adopted by the bureau, to medications approved and reimbursed by the self-insuring employer:

(1) The bureau may publish supply limitations for drugs which represent the maximum number of days supply that may be dispensed at any one time for a single prescription.

(2) The bureau may publish maximum prescription quantities which represent the largest number of units per drug that may be dispensed at any one time for a single prescription.

(3) Requests submitted that exceed either the days supply limit or maximum quantity limit shall be denied; provided, however, that the pharmacy provider may still fill the prescription up to the days supply limit or maximum quantity limit, as applicable. Denials may be overridden by the self-insured employer in cases where medical necessity and appropriateness have been determined.

(4) Refills of drugs not scheduled by the DEA requested before eighty per cent of any published days supply limit has been utilized will be denied.

(5) Refills of drugs scheduled by the DEA requested before ninety per cent of any published days supply limit has been utilized will be denied.

(6) Denials may be overridden by the self-insured employer for the following reasons with supporting documentation:

(a) The injured worker's pharmacy is submitting an early refill for a shortened days supply to support synchronizing the filling or refilling of the prescription in a manner that allows the dispensed drug to be obtained on the same date each month;

(b) The injured worker is traveling out of the country and will be unable to refill medications during that time;

(c) The injured worker's pharmacy will be closed for more than two days.

(d) An emergency or disaster, as defined in division (O) of section 4123.511 of the Revised Code, is declared by the governor of Ohio or the president of the United States.

(N) Self-insuring employers utilizing a pharmacy benefits manager may apply the maximum allowable cost list of the pharmacy benefits manager.

(O) Injured workers who request a brand name drug or whose physician specifies a brand name drug designated by "dispense as written" on the prescription for a medication for which pharmaceutically and therapeutically equivalent medications exist, as defined in paragraph (I) of rule 4123-6-21 of the Administrative Code, shall be liable for the product cost difference between the AWP of the dispensed brand name drug minus fifteen per cent and the established maximum allowable cost price of the drug product. However, the self-insuring employer or its vendor may approve reimbursement of the dispensed brand name drug at the AWP of the drug minus fifteen per cent if the following circumstances are met:

(1) The injured worker has a documented, systemic allergic reaction as a result of taking the generic equivalent which is consistent with known symptoms or clinical findings of a medication allergy; or

(2) The injured worker has been prescribed, and has tried, another generic equivalent and the intended therapeutic benefit has not been achieved or an unacceptable adverse event has occurred.

(P) A self-insuring employer has sufficient grounds to refuse to pay for the dispensing of drugs and other medications when a pharmacy provider fails to observe any state or federal law relating to his or her professional licensure or to the dispensing of drugs and other medication.

Last updated October 30, 2024 at 2:39 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.35, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 8/1/2025
Prior Effective Dates: 12/1/2013, 4/10/2014
Rule 4123-6-21.2 | Pharmacy and therapeutics committee.
 

The bureau of workers' compensation pharmacy and therapeutics (P&T) committee was created to advise the administrator, the chief of medical services, and the chief medical officer with regard to medication therapy issues for injured workers. The bureau will develop and maintain 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 and osteopathic medical schools, deans of Ohio's colleges of pharmacy, presidents of Ohio's various allopathic and osteopathic medical associations, the Ohio pharmacists association, the Ohio state medical board, and the Ohio state board of pharmacy.

(A) The P&T committee consists of the bureau's pharmacy program director, chief medical officer, and not more than thirteen nor less than five voting members who are licensed physicians and licensed pharmacists representing the diverse group of providers that provide medical care to the injured workers of Ohio as administered through the bureau. Subject to approval by the administrator, the committee may create any subcommittees the committee determines are necessary to assist the committee in performing its duties. Subcommittees will submit their recommendations to the P & T committee.

(B) P&T committee members must:

(1) Be familiar with issues relating to the treatment of injured workers in the Ohio workers' compensation system.

(2) Be a doctor of medicine (MD) or doctor of osteopathic medicine (DO), if a physician.

(3) Possess significant clinical or administrative experience in health care delivery, including but not limited to pain management, pharmacy practice, medical quality assurance, disease management, and utilization review.

(4) Have experience with and an understanding of the concepts of evidence-based medicine as well as contemporary best practices in their respective areas of practice.

(5) Not be, or within the previous twenty-four months have been, an employee of any pharmaceutical manufacturer, pharmacy benefits manager, or any non-governmental firm or entity administering state purchased health care program benefits or pharmaceutical rebates.

(C) The appointing authority for members of the P&T committee is the administrator or the administrator's designee(s), who will appoint members of the committee from the list of qualified providers developed and maintained by the bureau. Terms of membership for individual members of the P&T committee are for one year. Individuals may be reappointed to subsequent terms as determined by the administrator. Members may resign or be removed by the administrator at any time. Vacated terms are filled in a like manner as for the full term appointments for the remaining term of the vacated member.

(D) The pharmacy program director of the bureau is the chairperson of the P&T committee and is responsible for providing notice of meetings to the members and for the meeting agenda. In addition, the pharmacy program director may be self-designated as an ad hoc member of any subcommittees of the P&T committee. However, the pharmacy program director is only a voting member of the P&T committee and any subcommittees in the case of tie votes. The bureau's chief medical officer and the industrial commission's medical advisor may participate in discussions; however, they are not voting members. The pharmacy program director may designate an alternate to serve in the director's absence.

(E) The P&T committee will develop and establish bylaws for the organization and operations of the committee and subcommittees, consistent with the provisions of this rule and approval by the administrator and the chief medical officer.

(F) The P&T committee may make such recommendations as it deems necessary to address any issue impacting the bureau related to pharmacy or medication therapeutics. The committee is responsible for responding to requests for recommendation on any such issue submitted by the bureau's administrator, chief of medical services, chief medical officer, or pharmacy program director, including:

(1) Development and review of a formulary of approved medications.

(2) Development of prior authorization criteria.

(3) Review of proposed medication treatment guidelines.

(4) Review of clinical criteria related to drug utilization review or specific medication issues.

(5) Review of the bureau's pharmacy providers' professional performance. Any peer review conducted by the P&T committee will be in accordance with generally accepted standards of pharmacy practice. The P&T committee may recommend sanctions as well as termination of any pharmacy provider determined to have consistently failed to meet such standards.

(6) Review of any of the bureau's medical providers' medication prescribing patterns and practices. Any peer review conducted by the P&T committee will be in accordance with generally accepted standards of medical practice applicable to medication prescribing. The P&T committee may recommend sanctions as well as decertification of any provider determined to have consistently failed to meet such standards. Any decertification or sanction of a provider by the bureau pursuant to recommendation of the P&T committee will be conducted in accordance with rule 4123-6-17 of the Administrative Code.

(7) Review of the bureau's pharmacy benefit manager's performance and conduct regarding its management of prescription benefit services for the bureau.

(G) The P&T committee will hold at least two meetings annually. The P&T committee and all subcommittees will keep written records of the agenda and minutes of each meeting, which will be maintained by the bureau.

(H) The P&T committee will submit an annual report of its activities and recommendations to the administrator.

(I) Each member of the P&T committee and its respective subcommittees may be paid such fees as approved by the administrator or the administrator's designee. The expenses incurred by the P&T committee and its subcommittees and the fees of their members are paid in the same manner as other administrative costs of the bureau.

Last updated October 30, 2024 at 2:39 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 2/1/2027
Prior Effective Dates: 1/10/2011
Rule 4123-6-21.3 | Outpatient medication formulary.
 

(A) The administrator hereby adopts the formulary indicated in the appendix to this rule, developed with the recommendation of the bureau's pharmacy and therapeutics committee.

(B) Except as otherwise provided in paragraph (F) of this rule, the formulary indicated in the appendix to this rule shall constitute the complete list of medications that are approved for reimbursement by the bureau for the treatment of a work related injury or disease in an allowed claim when dispensed to an injured worker by a registered pharmacist from an enrolled outpatient pharmacy provider.

(C) The formulary indicated in the appendix to this rule also contains specific reimbursement, prescribing or dispensing restrictions that have been placed on the use of listed drugs. The formulary will be reviewed and updated as necessary. The most current version will be electronically published by the bureau.

(D) The administrator will consider current medical literature and best practices and the recommendations of the bureau's pharmacy and therapeutics committee when making additions, deletions, or modifications of coverage of medications listed in the formulary.

(E) The bureau shall provide an expedited review process for clinically or therapeutically unique medications when necessary.

(F) Notwithstanding paragraph (B) of this rule, in cases of medical necessity supported by medical documentation and evidence of need the bureau may reimburse for:

(1) New drugs approved for use in the United States by the food and drug administration (FDA) on or after the effective date of the formulary, and for new indications approved by the FDA on or after the effective date of the formulary for existing drugs that are not on the formulary, with prior authorization, for a period not to exceed one hundred eighty days from the adjudication date of the first prescription for the requested drug.

(2) Antineoplastic drugs prescribed for treatment of an allowed cancer condition in a claim.

(3) Antiretroviral drugs prescribed for:

(a) Treatment of an allowed condition of human immunodeficiency virus in a claim; or

(b) Post exposure treatment in an allowed claim or pursuant to section 4123.026 of the Revised Code.

(G) Notwithstanding the appendix to this rule, in cases of medical necessity supported by medical documentation and evidence of need the bureau may reimburse for new dosage forms or strengths approved by the FDA on or after the effective date of the formulary for existing drugs that are on the formulary, with prior authorization, for a period not to exceed one hundred eighty days from the adjudication date of the first prescription for the requested drug.

View Appendix

Last updated October 30, 2024 at 2:39 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 5/1/2025
Prior Effective Dates: 2/1/2012, 9/1/2012, 4/1/2013, 1/2/2014, 9/1/2014, 8/1/2021, 8/1/2022, 2/1/2023
Rule 4123-6-21.4 | Coordinated services program.
 

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 may review an injured worker for possible placement in a CSP if a review of the claim indicates the injured worker meets one or more of the following criteria:

(a) Use of three or more different prescribers to obtain prescriptions of the same or comparable medications per three month time frame;

(b) Receipt of prescription drugs from more than two different pharmacies per three month time frame;

(c) Monthly receipt of three or more prescriptions including refills for drugs identified by therapeutic drug class as a narcotic analgesic per three month time frame;

(d) Monthly receipt of more than two concurrent narcotic analgesics in the same therapeutic drug class per three month time frame;

(e) Monthly receipt of more than two narcotic analgesics in the same therapeutic drug class, more than one benzodiazepine, and more than one sedative-hypnotics per three month time frame.

(2) Upon identification of an injured worker meeting one or more of the criteria identified in paragraphs (A)(1)(a) to (A)(1)(e) of this rule, the bureau or self-insuring employer with a point-of-service adjudication system shall obtain a physician review of the injured worker's most recent twelve months history of prescription medications reimbursed by the bureau or self-insuring employer.

(3) If, based on this physician review, the bureau or self-insuring employer with a point-of-service adjudication system determines that the injured worker's utilization of prescription medications during this period was at a frequency or in an amount that was not medically necessary or appropriate under the criteria set forth in paragraphs (B)(1) to (B)(3) of rule 4123-6-16.2 of the Administrative Code, or was potentially unsafe, the bureau or self-insuring employer may place the injured worker in a CSP.

(4) Notwithstanding paragraphs (A)(1) to (A)(3) of this rule, if the bureau or self-insuring employer with a point-of-service adjudication system determines that an injured worker has been convicted of or pled guilty to an offense under Chapter 2925. of the Revised Code or any other criminal offense related to the misuse of drugs, the bureau or self-insuring employer may place the injured worker in a CSP.

(5) Placement in a CSP shall be for an initial period of eighteen months. The bureau or self-insuring employer with a point-of-service adjudication system may place the injured worker in the CSP for additional eighteen month periods in accordance with paragraph (A)(6) of this rule.

(6) The bureau or self-insuring employer with a point-of-service adjudication system may evaluate an injured worker's medication utilization at the conclusion of each eighteen month period in the CSP. If the bureau or self-insuring employer determines that the injured worker's medication utilization continues to meet the criteria set forth in paragraphs (A)(1) to (A)(4) of this rule, the bureau or self-insuring employer may place the injured worker in the CSP for an additional eighteen month period.

(7) If an injured worker placed in the CSP enters a nursing home, residential care/assisted living facility, or hospice program, the injured worker shall be released from the CSP. If the injured worker is subsequently discharged from the nursing home, residential care/assisted living facility, or hospice program during the CSP period, the bureau or self-insuring employer with a point-of-service adjudication system may place the injured worker back into the CSP.

(B) Selection of designated pharmacy and/or prescriber.

(1) An injured worker placed into a CSP pursuant to paragraph (A)(3) or (A)(4) of this rule shall be given the opportunity to select a designated pharmacy from a list of participating pharmacies maintained by the bureau or self-insuring employer. If an injured worker fails to select a designated pharmacy, or selects a designated pharmacy that is unable or unwilling to accept the injured worker, the bureau or self-insuring employer may select a designated pharmacy for the injured worker.

(2) An injured worker placed in a CSP pursuant to paragraph (A)(3) or (A)(4) of this rule may only change from one designated pharmacy to another in the following circumstances:

(a) The designated pharmacy becomes inaccessible to the injured worker due to relocation or incapacity of the injured worker or closing of the designated pharmacy,

(b) The designated pharmacy chooses to no longer participate in the CSP or to provide services to the injured worker in accordance with paragraph (D)(4) of this rule.

(c) The injured worker requests to be assigned to another designated pharmacy due to personal preference. Not more than one change due to personal preference shall be approved in a rolling twelve-month period.

(3) An injured worker placed in the CSP pursuant to paragraph (A)(4) of this rule shall be given the opportunity to select a designated prescriber from among those bureau certified providers who meet the definition of physician under paragraph (P) of rule 4123-6-01 of the Administrative Code. If an injured worker fails to select a designated prescriber, or selects a designated prescriber that is unable or unwilling to accept the injured worker, the bureau or self-insuring employer may select a designated prescriber for the injured worker.

(4) An injured worker placed in a CSP pursuant to paragraph (A)(4) of this rule may only change from one designated prescriber to another in the following circumstances:

(a) The designated prescriber becomes inaccessible to the injured worker due to relocation or incapacity of the injured worker or closing of the designated prescriber's practice,

(b) The designated prescriber chooses to no longer provide services to the injured worker,

(c) The injured worker requests to be assigned to another designated prescriber due to personal preference. Not more than one change due to personal preference shall be approved in a rolling twelve-month period.

(5) All requests for change of designated pharmacy or designated prescriber must be submitted in writing to the bureau or self-insuring employer.

(C) Operation of the CSP.

(1) An injured worker placed in a CSP pursuant to paragraph (A)(3) or (A)(4) of this rule must obtain covered prescription medications from the injured worker's designated pharmacy. During the period the injured worker is placed in the CSP, the bureau or self-insuring employer shall deny reimbursement for prescription medications obtained from a pharmacy other than the injured worker's designated pharmacy, except in cases of emergency as set forth in paragraph (C)(2) of this rule.

(2) Emergency prescription fills shall be allowed in the following situations:

(a) The injured worker is unable to get to their designated pharmacy,

(b) The injured worker's designated pharmacy does not have the prescribed medication in stock.

(3) Emergency prescription fills shall be limited to a four-day supply. Records of dispensing for emergency prescription fills are subject to review by the bureau.

(4) An injured worker placed in a CSP pursuant to paragraph (A)(4) of this rule must obtain all prescriptions for covered medications from the injured worker's designated prescriber. During the period the injured worker is placed in the CSP, the bureau or self-insuring employer shall deny reimbursement for prescriptions written by providers other than the injured worker's designated prescriber, except:

(a) In cases of emergency as defined in paragraph (F) of rule 4123-6-01 of the Administrative Code;

(b) With prior authorization, prescriptions written by a specialist in cases where the injured worker has been referred to a specialist for care.

(D) Pharmacies participating in the bureau's CSP.

(1) The bureau shall maintain a list of pharmacies participating in the bureau's CSP that are eligible for selection by an injured worker as a designated pharmacy. To participate in the bureau's CSP, a pharmacy must meet the following criteria:

(a) The pharmacy must be enrolled with the bureau and have a signed agreement with the bureau's pharmacy benefits manager.

(b) The pharmacy must enter into a CSP agreement with the bureau.

(2) Pharmacies participating in the bureau's CSP agree to perform the following monitoring activities:

(a) For each injured worker in the bureau's CSP for whom the pharmacy is the designated pharmacy, the pharmacy shall conduct a bimonthly review of the injured worker's OARRS report from the Ohio board of pharmacy (or a similar automated prescription monitoring report from the injured worker's state of residence).

(b) The pharmacy shall notify the injured worker's prescribing physician of any critical findings discovered in the report. Critical findings are indications of any prescription related activity that could cause harm to the patient, including but not limited to:

(i) Duplication of therapy,

(ii) Excessive doses of concurrent medications,

(iii) Potential drug interactions or potentiation of side effects.

(c) The pharmacy shall notify BWC in writing whenever reports are made under paragraph (D)(2)(b) of this rule.

(d) BWC may request quarterly documentation of the pharmacy's monitoring activities under paragraphs (D)(2)(a) to (D)(2)(d) of this rule.

(3) Pharmacies participating in the CSP may receive compensation from the bureau under the CSP agreement for services provided as part of the CSP.

(4) Pharmacies participating in the bureau's CSP may terminate their CSP agreement with the bureau and discontinue their participation in the bureau's CSP at any time upon not less than thirty days written notice to the bureau. Pharmacies participating in the bureau's CSP may discontinue providing services to an individual injured worker at any time upon not less than thirty days written notice to the bureau, the injured worker, and the injured worker's authorized representative.

(5) The bureau may terminate the CSP agreement of a pharmacy participating in the bureau's CSP in accordance with the terms of the CSP agreement.

(E) Pharmacies participating in a self-insuring employer's CSP.

(1) A self-insuring employer with a point-of-service adjudication system who establishes a CSP shall maintain a list of pharmacies participating in the self-insuring employer's CSP that are eligible for selection by an injured worker as a designated pharmacy. The list of participating pharmacies shall cover a geographic area sufficient to provide the self-insuring employer's injured workers with reasonable access to pharmacy providers.

(2) Pharmacies participating in a self-insuring employer's CSP shall provide not less than thirty days written notice to an injured worker and the injured worker's authorized representative prior to discontinuing services to the injured worker.

(F) Disputes.

(1) Decisions by the bureau regarding an injured worker's placement in the bureau's CSP, assignment of a designated pharmacy or designated prescriber, or denial of an injured worker's request for change of designated pharmacy or designated prescriber may be appealed to the industrial commission in accordance with section 4123.511 of the Revised Code.

(2) Decisions by a self-insuring employer regarding an injured worker's placement in the self-insuring employer's CSP, assignment of a designated pharmacy or designated prescriber, or denial of an injured worker's request for change of designated pharmacy or designated prescriber shall indicate that the injured worker has the right to request a hearing before the industrial commission.

Last updated October 30, 2024 at 2:39 PM

Supplemental Information

Authorized By: 4121.121, 4121.44, 4121.441, 4121.50, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4121.50, 5164.758, 5167.13
Five Year Review Date: 2/1/2027
Prior Effective Dates: 6/1/2012
Rule 4123-6-21.5 | Standard dose tapering schedules.
 

(A) The bureau hereby adopts the standard dose tapering (weaning) schedules for the prescription medications indicated in this rule, and the appendix to this rule.

(B) These weaning schedules apply to denials for payment of the indicated medications by the bureau, self-insuring employers, MCOs, QHPs, and the industrial commission when:

(1) The medication has been previously allowed for treatment of an allowed condition in the claim;

(2) The denial is based upon a finding that the medication is no longer medically necessary or appropriate for treatment of the allowed condition; and

(3) The prescriber has submitted a written treatment plan reflecting an intention to discontinue the medication and a request for reimbursement of the weaning period.

(C) The approved weaning duration will be the weaning period requested by the prescriber, or the weaning period outlined in this rule or the appendix to this rule, whichever is less.

(D) Weaning from opioids: Upon denial of reimbursement for an opioid, reimbursement for a weaning period will only be approved if the prescribed total daily morphine equivalent dose is sixty or greater.

(1) The approved duration of the opioid weaning period must allow for a ten percent reduction of the total daily morphine equivalent dose per week, or a larger reduction with a shorter duration as requested by the prescriber.

(2) Requests to approve additional time for weaning for rates slower than a ten per cent dose reduction per week will be denied.

(E) Weaning from benzodiazepines: The weaning period for benzodiazepines is set forth in the appendix to this rule.

Last updated October 30, 2024 at 2:39 PM

Supplemental Information

Authorized By: 4121.12, 4123.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 2/1/2027
Prior Effective Dates: 4/10/2014
Rule 4123-6-21.6 | First fill of outpatient medications.
 

(A) In accordance with division (B) of section 4123.66 of the Revised Code, the administrator has established a program to make immediate payment, under the circumstances set forth in this rule, for the first fill of prescription drugs for medical conditions identified in an application for compensation or benefits under section 4123.84 or 4123.85 of the Revised Code that occurs prior to the date the administrator issues an initial determination order under division (B) of section 4123.511 of the Revised Code.

(B) The appendix to this rule shall constitute the complete list of medications, and the maximum quantity of such medications, that are approved for reimbursement by the bureau for first fill prior to issuance of an initial determination order. Except as otherwise provided in paragraph (C) of this rule, drugs not listed in the appendix to this rule are not eligible for reimbursement by the bureau under the first fill program.

(C) Notwithstanding paragraph (B) of this rule, in cases of medical necessity supported by clinical documentation and evidence of need the bureau may, with prior authorization, reimburse for the first fill of medications that are eligible for reimbursement under rule 4123-6-21.3 of the Administrative Code but are not listed in the appendix to this rule.

(D) Reimbursement of outpatient medications by the bureau under the first fill program shall be subject to the following limitations:

(1) Approval for reimbursement of medications under the first fill program will be limited to the quantity limits listed in the appendix to this rule, and no refills will be approved;

(2) With the exception of antivirals, antiretrovirals, and antibiotics, approval for reimbursement of medications under the first fill program will be limited to one drug per therapeutic drug class listed in the appendix to the rule;

(3) Extemporaneous compounded prescriptions are not eligible for reimbursement by the bureau under the first fill program.

(E) Pharmacy providers shall be reimbursed for dispensing drugs under this rule in the manner described in rule 4123-6-21 of the Administrative Code provided that the prescriber, or their agent has indicated the prescription is for a work related injury and signed the prescription blank. A pharmacist or pharmacy intern who receives a telephone prescription may also write and sign that it is work related on the prescription.

(F) If a claim in which the first fill of outpatient medication was reimbursed by the bureau pursuant to this rule is ultimately disallowed in a final administrative or judicial order, and if the employer is a state fund employer who pays assessments into the surplus fund account created under section 4123.34 of the Revised Code, the payment for outpatient medication made pursuant to this rule shall be charged to and paid from the surplus fund account and not charged through the state insurance fund to the employer against whom the claim was filed.

Last updated October 30, 2024 at 2:39 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.34, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 5/1/2025
Prior Effective Dates: 9/1/2020, 2/1/2022, 2/1/2024
Rule 4123-6-21.7 | Reimbursement of opioids in the treatment of pain for a work related injury or occupational disease.
 

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" means the "Ohio Automated Rx Reporting System" drug database established and maintained pursuant to section 4729.75 of the Revised Code.

(3) "Opioid" has the same meaning as "opioid analgesic" as defined in section 3719.01 of the Revised Code.

(B) Reimbursement for opioid prescriptions used to treat a work related injury or occupational disease is limited to claims in which current best medical practices as implemented by rules 4731-11-13 and 4731-11-14 of the Administrative Code and this rule are followed.

The bureau will not reimburse for any further prescriptions for opioids if the applicable criteria of rules 4731-11-13 and 4731-11-14 of the Administrative Code and this rule are not met. A prescriber's failure to comply with these rules may be subject to peer review by the bureau of workers' compensation pharmacy and therapeutics (P&T) committee pursuant to rule 4123-6-21.2 of the Administrative Code, the bureau of workers' compensation stakeholders' health care quality assurance advisory committee (HCQAAC) pursuant to rule 4123-6-22 of the Administrative Code, or other peer review committee established by the bureau, or subject to decertification pursuant to rule 4123-6-02.7 of the Administrative Code.

(C) Opioid utilization for acute pain.

Reimbursement for ongoing opioid prescriptions for acute pain will only be provided when the prescriber has both complied with rule 4731-11-13 of the Administrative Code and has documented in the medical record the appropriateness and safety of the medication in the same manner as in paragraphs (A) and (B) of rule 4731-11-14 of the Administrative Code.

(D) Opioid utilization for subacute and chronic pain.

(1) Ongoing reimbursement for opioid prescriptions for subacute and chronic pain will only be provided when the prescriber has complied with rule 4731-11-14 of the Administrative Code.

(2) In addition to paragraph (D)(1) of this rule, when prescribing opioids at or above an average daily dose of fifty MED per day, the prescriber must complete and document in the patient records:

(a) A validated risk assessment, not less than every three months; and

(b) Urine drug screens, with frequency based upon the results of the validated risk assessment and upon presence or absence of aberrant behaviors or other indications of substance misuse, abuse, substance use disorder, or diversion.

(E) Paragraph (D) of this rule does not apply when the opioid is prescribed for an injured worker in the situations described in paragraph (H) of rule 4731-11-14 of the Administrative Code.

Last updated October 30, 2024 at 2:39 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 5/1/2025
Prior Effective Dates: 10/1/2016
Rule 4123-6-21.8 | Reimbursement for Services to Assist in the Discontinuation of Medications.
 

This rule governs the bureau's reimbursement for services to aid injured workers in discontinuing medications which may be necessary and appropriate in the treatment of work related injuries, but which may increase the risk of dependency, misuse, and substance use disorder in some injured workers if continued. Medically necessary and appropriate services to aid injured workers in discontinuing these medications may include services which provide functional restoration and pharmacologic and non-pharmacologic treatment alternatives.

(A) Assessment services will be reimbursed when the medical documentation reflects:

(1) The injured worker is currently receiving a medication prescribed for and reimbursed in the injured worker's claim;

(2) The injured worker has expressed a desire to discontinue the medication(s) and is willing to participate in a treatment program; and

(3) The physician of record determines, based on clinical observation and other factors, that a dependency assessment may be appropriate.

(B) Ongoing services, subject to paragraph (C) of this rule, will be reimbursed when the results of the dependency assessment indicate treatment is medically necessary and appropriate to aid in the discontinuation of the medication and a treatment plan and monthly documentation of the injured worker's participation and progress in the treatment plan are submitted.

(C) The bureau will reimburse outpatient, inpatient, or any combination of inpatient and outpatient treatment for the purpose of discontinuing medication for:

(1) Up to a total of forty-two days of inpatient care during the life of the claim; and

(2) Up to a total of eighteen months of outpatient care during the life of the claim.

(D) The bureau will reimburse medically necessary and appropriate medications prescribed for assisting the injured worker's discontinuance of the targeted medication.

Last updated October 30, 2024 at 2:39 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 5/1/2025
Rule 4123-6-22 | Stakeholders' health care quality assurance advisory committee.
 

The bureau of workers' compensation stakeholders' health care quality assurance advisory committee (HCQAAC) was created to advise the administrator, the chief of medical services, and the chief medical officer with regard to medical 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 limited to: deans of Ohio's allopathic and osteopathic medical schools, deans of Ohio's colleges of pharmacy, deans of Ohio's dental schools, the dean of the Ohio college of podiatric medicine, the Ohio state medical association, the Ohio state osteopathic association, the Ohio state chiropractic association, specialty board associations of Ohio, the Ohio podiatric medical association, the Ohio psychological association, the Ohio dental association, the Ohio pharmacists association, the Ohio hospital association, the Ohio state medical board, the Ohio state chiropractic board, the Ohio state psychology board, the Ohio state pharmacy board, and the Ohio state dental board.

(A) The HCQAAC shall consist of the bureau's chief medical officer, the chief of medical services and not more than thirteen nor less than five voting members representing the diverse group of providers that provide medical care to the injured workers of Ohio as administrated through the bureau. The committee may create any subcommittees that the committee determines are necessary to assist the committee in performing its duties. Any subcommittee recommendations shall be submitted to the HCQAAC committee.

(B) HCQAAC members must meet the following requirements:

(1) Providers must be familiar with issues relating to the treatment of injured workers in the Ohio workers' compensation system.

(2) Providers must possess significant clinical or administrative experience in health care delivery, including but not limited to, medical quality assurance, disease management, and utilization review.

(3) Providers must have experience with and an understanding of the concepts of evidence based medicine as well as contemporary best practices in their respective areas of practice.

(C) The appointing authority for members of the HCQAAC shall be the administrator or the administrator's designee(s), who shall appoint members of the HCQAAC from the list of qualified providers developed and maintained by the bureau. Terms of membership for individual members of the HCQAAC shall be for one year. Individuals may be reappointed to subsequent terms as determined by the administrator. Vacated terms shall be filled in a like manner as for the full term appointments and shall be for the remaining term of the vacated member.

(D) The chief medical officer of the bureau shall be the chairperson of the HCQAAC and shall provide notice of meeting to the members and be responsible for the meeting agenda. In addition, the chief medical officer and chief of medical services may be self-designated as an ad hoc member of any subcommittees of the HCQAAC. However, the chief of medical services is not a voting member of the HCQAAC or any subcommittee, and the chief medical officer is a voting member of the HCQAAC and any subcommittees only in the case of tie votes. The industrial commission's medical advisor, and one physician chosen by the MCOs may participate in discussions; however, they are not voting members.

(E) The HCQAAC shall develop and establish bylaws for the organization and operations of the committee and subcommittees, subject to the requirements of this rule and approval by the administrator and the chief medical officer.

(F) The HCQAAC shall be responsible to respond to requests for recommendation on any medical quality assurance issue submitted by the bureau's administrator, chief of medical services, or chief medical officer including :

(1) Review of medical treatment guidelines referred to the bureau;

(2) Review of any of the bureau's policies and procedures related to medical quality assurance issues;

(3) Review of any of the bureau's medical providers' professional performance and conduct, including bureau certification and malpractice issues. Any peer review conducted by the HCQAAC will be in accordance with generally accepted standards of medical practice. The HQAAC may recommend sanctions as well as decertification of any provider determined to have consistently failed to meet such standards . Any decertification or sanction of a provider by the bureau pursuant to recommendation of the HCQAAC will be conducted in accordance with rule 4123-6-17 of the Administrative Code;

(4) Review of any of the bureau's managed care organizations' professional performance and conduct regarding the management of medical services for the bureau. This may include interfacing with any quality assurance committee of any of the individual managed care organizations.

The HCQAAC may make such recommendations as it deems necessary to address any medical quality assurance issue impacting the bureau.

(G) The HCQAAC shall hold at least quarterly meetings. The HCQAAC and all subcommittees shall keep written records of the agenda and minutes of each meeting, which will be maintained by the bureau.

(H) The HCQAAC shall submit an annual report of its activities and recommendations to the administrator.

(I) Each member of the HCQAAC and its respective subcommittees may be paid such fees as approved by the administrator or administrator's designee. The expenses incurred by the HCQAAC and its subcommittees and the fees of their members shall be paid in the same manner as other administrative costs of the bureau.

Last updated February 1, 2022 at 9:34 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: : 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 2/1/2027
Prior Effective Dates: 6/1/2005
Rule 4123-6-25 | Payment for medical supplies and services.
 

(A) Medical or other services to be approved for payment must be rendered as a result of an injury sustained or occupational disease contracted by an injured worker in the course of and arising out of employment. The claim must be allowed by an order of either the bureau of workers' compensation or the industrial commission, or have been recognized by a self-insuring employer.

Medical supplies and services will be considered for payment when they are reasonably related to the work related injury, the requested services are reasonably necessary for treatment of the work related injury, and the costs of the services are medically reasonable. Payment for services rendered to an injured 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 supervision of the service, as in effect on the billed date of service, unless otherwise specified in the bureau's provider billing and reimbursement manual in effect on the billed date of service. By submitting any fee bill to the bureau, in either hardcopy or electronic format, the health care provider affirms that medical supplies and services have been provided to the injured worker as required by this rule.

Providers billing for services rendered shall follow the procedures set forth in the bureau's provider billing and reimbursement manual in effect on the billed date of service.

(B) Services rendered by health care providers are subject to review for coding requirements outlined in paragraph (C) of this rule. Payments to health care providers may be adjusted based upon these guidelines.

(C) Coding systems.

(1) Billing codes.

(a) Practitioners are required to use the edition of the CMS healthcare common procedure coding system (HCPCS) in effect on the billed date of service to indicate the procedure or service rendered to injured workers.

(b) Inpatient and outpatient hospital services must be billed using the national uniform billing committee's revenue center codes in effect on the billed date of service (date of discharge for inpatient services).

(c) To insure accurate data collection, the bureau shall adopt a standardized coding structure which shall be adopted by any MCO, QHP, or self-insuring employer.

(2) Diagnosis codes.

Providers must use the appropriate "International Classification of Diseases, clinical modification" codes for the condition(s) treated to indicate diagnoses.

(D) Prior to services being delivered, the provider must make reasonable effort to notify the injured worker, bureau, MCO, QHP or self-insuring employer when the provider has knowledge that the services may not be related to the claimed or allowed condition(s) related to the work related injury or illness, or that a service is non-covered. The provider may not knowingly bill or seek payment from the bureau, MCO, QHP or self-insured employer for services that are not related to the claimed or allowed condition(s) related to the work related injury or illness. The provider may not knowingly mislead or direct providers of ancillary services to bill or seek payment for services that are not related to the claimed or allowed condition.

The provider may not bill or seek payment from the injured worker for services determined as medically unnecessary through the use of bona fide peer review based on accepted treatment guidelines.

Last updated February 1, 2022 at 9:34 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 2/1/2027
Prior Effective Dates: 4/1/2007
Rule 4123-6-26 | Claimant reimbursement.
 

(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 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 the amount that would have been paid to the health care provider as provided by this chapter.

(1) In cases where the payor is the claimant's health insurer, if the claimant seeks reimbursement for an out-of-pocket copayment, the claimant may be reimbursed for the copayment and the claimant's health insurer may be reimbursed up to the amount that would have been paid to the health care provider as provided by this chapter.

(2) In cases where the claimant pays a pharmacy out of pocket for an outpatient medication because the medication is not payable under division (I) of section 4123.511 of the Revised Code on the date of service, if the medication later becomes payable, the claimant may be reimbursed the full amount of the claimant's out-of-pocket payment.

(B) When the bureau has already made payment to the health care provider, the payor shall be informed to seek reimbursement from the provider. The bureau shall inform a claimant or payor whether a health care provider participates in the HPP or QHP.

(C) Requests for reimbursement pursuant to this rule shall be subject to the timeframes set forth in division (B) of section 4123.52 of the Revised Code and in rule 4123-3-23 of the Administrative Code.

Last updated February 1, 2022 at 9:35 AM

Supplemental Information

Authorized By: 4121.12, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 2/1/2027
Prior Effective Dates: 6/24/2011
Rule 4123-6-27 | Treatment by more than one physician.
 

Medical fees shall not be approved for treatment by more than one physician for the same condition over the same period of time, except where a consultant, anesthetist, or assistant is required, or where the necessity for treatment by a specialist is clearly shown and approved in advance of treatment. This rule does not apply in cases of emergency, or where the physician of record's approved treatment plan indicates the necessity for multidisciplinary services.

Last updated May 31, 2023 at 11:03 AM

Supplemental Information

Authorized By:
Amplifies:
Five Year Review Date:
Rule 4123-6-29 | Request for information by the treating provider.
 

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 request.

Last updated May 31, 2023 at 11:03 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 11/1/2026
Prior Effective Dates: 2/14/2005
Rule 4123-6-30 | Payment for physical medicine.
 

(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 consultative services. "Physical measures" include massage, heat, cold, air, light, water, electricity, sound, manipulation, and the performance of tests of neuromuscular function as an aid to such treatment. Physical medicine does not include the diagnosis of a patient's disability, the use of roentgen rays or radium for diagnostic or therapeutic purposes, or the use of electricity for cauterization or other surgical purposes. Physical medicine includes, but not limited to, chiropractic treatments, physiotherapy, and physical therapy.

(B) Physical medicine must be prescribed by the physician 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 provider.

(C) To be eligible for reimbursement, physical medicine services must be provided by a physician or chiropractic physician, or a physical therapist, occupational therapist, massage therapist, athletic trainer, or other qualified non-physician provider practicing within the scope of their license, certification, or registration.

(D) Fees for up to twelve physical medicine treatments within sixty days following the date of injury may be reimbursed without prior authorization, provided the treatments are for allowed soft tissue and musculoskeletal conditions in allowed claims and the criteria set forth in paragraphs (B)(1) to (B)(3) of rule 4123-6-16.2 of the Administrative Code are met. Otherwise, physical medicine treatment must be prior authorized.

Last updated February 1, 2022 at 9:35 AM

Supplemental Information

Authorized By: : 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 2/1/2027
Prior Effective Dates: 11/13/2015
Rule 4123-6-31 | Payment for miscellaneous medical services and supplies.
 

(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 compliance with Chapter 4762. of the Revised Code.

(B) Orthotic devices.

(1) Payment is made only for those orthotic devices prescribed in writing by the physician of record or treating physician for treatment of an allowed injury or occupational disease.

(2) Orthotic devices are eligible for reimbursement only when custom fitted or custom fabricated and delivered to the satisfaction of the prescribing physician and the administrative agencies. Repairs, modifications, and adjustments to secure satisfactory application of the orthotic appliance will be made within sixty days of fitting and application without additional charge by the supplier of the orthotic device.

(3) Measurement, transportation, or other expenses incurred by the supplier-orthotist are not eligible for reimbursement, except when the supplier-orthotist needs to travel beyond the limits of the metropolitan community in which they maintain their place of business by reason of the physical incapacity of the claimant or by reason of direct prescription by the attending physician. The supplier-orthotist in those circumstances will be paid for traveling expenses on a round-trip basis when separately specified on the supplier-orthotist's billing, including the points of travel and the name of the physician prescribing the travel. Payment will be made for a maximum of three round-trip calls.

(C) Dental care.

(1) Payment for dental care will be made in the following cases:

(a) Where the work related accident causing the injury also results in the damage or loss of the injured worker's artificial teeth or other denture. Once the artificial teeth or other denture(s) have been repaired, replaced, or adjusted, no further repair, replacement, or adjustment will be approved.

(b) Where a work related injury or occupational disease has caused damage or adversely affected the injured worker's natural teeth.

(2) Responsibility for the repair of both natural and artificial teeth is limited to the damage done at the time of the accident, or to the damage caused by an allowed injury or occupational disease.

(D) Eyeglasses and contact lenses.

(1) Payment for eyeglasses or contact lenses will be made in the following cases:

(a) Where the work related accident causing the injury also results in the damage or loss of the injured worker's eyeglasses or contact lenses. Once the eyeglasses or contact lenses have been repaired, replaced, or adjusted, no further repair, replacement, or adjustment will be approved.

(b) Where loss of vision is the result of an allowed injury or occupational disease.

(2) Refractions will be approved in situations described in paragraph (D)(1)(b) of this rule.

(3) When medical evidence indicates a need due to an allowed injury or occupational disease contact lenses may be approved instead of eyeglasses.

(4) Glasses or contact lenses will be approved for treatment purposes, when necessary, as a result of the allowed injury or occupational disease. Any subsequent adjustment or change in an injured worker's glasses or contact lenses, if medically necessary for treatment of the allowed injury or occupational disease, will also be approved.

(E) Hearing aids.

Payment for hearing aids will be made in the following cases:

(1) Where the work related accident causing the injury also results in the damage or loss of the claimant's hearing aid(s) Once the hearing aid(s) have been repaired, replaced, or adjusted, no further repair, replacement or adjustment will be approved.

(2) When a partial loss of hearing is the result of an allowed injury or occupational disease.

(F) Diagnostic testing, nerve injections, and imaging.

(1) Requests for diagnostic electromyography (EMG), nerve conduction study (NCS), epidural injections, nerve blocks, and medical imaging will be reimbursed when medical evidence shows that the diagnostic EMG, NCS, epidural injection, nerve block, or medical imaging is medically necessary either to develop a plan of treatment for, or to pursue more specific diagnoses reasonably related to, an allowed condition and the criteria of paragraphs (B)(1) to (B)(3) of rule 4123-6-16.2 of the Administrative Code are met.

(2) When the results of the diagnostic EMG, NCS, epidural injections, nerve block, or medical imaging indicate a non-allowed condition, therapeutic treatment for such non-allowed condition will not be reimbursed unless the condition is additionally allowed in the claim.

(3) Requests for duplicative diagnostic EMG, NCS, or medical imaging will not be reimbursed absent evidence of new or changed medical circumstances since the last diagnostic EMG, NCS, or medical imaging, or other medical evidence supporting the need for additional diagnostic testing or imaging that meets the criteria of paragraphs (B)(1) to (B)(3) of rule 4123-6-16.2 of the Administrative Code.

(4) With medical evidence supporting the necessity, reimbursement for diagnostic epidural injections or nerve blocks:

(a) May include up to three spinal levels, unilaterally or bilaterally, contiguous to the level of the allowed condition; and

(b) May include one repeat diagnostic injection to confirm a pain relief response prior to submission of requests for reimbursement of therapeutic treatment at the allowed level.

(5) Medical imaging includes magnetic resonance imaging (MRI), computed tomography scan (CT), discogram, positron emission tomography (PET), myelogram, X-ray, and ultrasound.

(G) Once payment for orthotic devices, artificial teeth or other dentures, eyeglasses, contact lenses, or hearing aids has been made, replacement requests may be denied in instances of malicious damage, neglect, culpable irresponsibility, or wrongful disposition.

Last updated June 3, 2024 at 8:32 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 2/1/2027
Prior Effective Dates: 2/14/2005
Rule 4123-6-32 | Payment for lumbar fusion surgery.
 

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 preclude, or substitute for, the surgeon's responsibility to exercise sound clinical judgment in light of current best medical practices 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 4123-6-22 of the Administrative Code or other peer review committee established by the bureau.

Medical treatment reimbursement requests (on form C-9 or equivalent) for lumbar fusion surgery are not subject to dismissal by the MCO pursuant to paragraph (F)(7) of rule 4123-6-16.2 of the Administrative Code.

(A) Prerequisites to consideration of lumbar fusion surgery.

Except as otherwise provided in paragraph (A)(4) of this rule, authorization for lumbar fusion shall be considered only in cases in which the following criteria are met:

(1) Conservative care.

(a) The injured worker must have had at least sixty days of conservative care for low back pain, with an emphasis on:

(i) Physical reconditioning;

(ii) Avoidance of opioids, when possible; and

(iii) Avoidance of provider catastrophizing the explanation of lumbar MRI findings.

(b) The injured worker's comprehensive conservative care plan may include, but is not limited to, one or more of the following:

(i) Relative rest/ice/heat;

(ii) Anti-inflammatories;

(iii) Pain management / physical medicine rehabilitation program;

(iv) Chiropractic / osteopathic treatment;

(v) Physical medicine treatment as set forth in rule 4123-6-30 of the Administrative Code;

(vi) Interventional spine procedures / injections.

(2) The operating surgeon requesting authorization for lumbar fusion surgery must have personally evaluated the injured worker on at least two occasions prior to requesting authorization for lumbar fusion surgery.

(3) The injured worker must have undergone a comprehensive evaluation, coordinated by both the injured worker's physician of record or treating physician and the operating surgeon, in which all of the following have been documented:

(a) Utilization and correlation of all of the following tools:

(i) Visual analog scale (VAS);

(ii) Pain diagram;

(iii) Oswestry low back disability questionnaire.

(b) A comprehensive orthopedic / neurological examination, including documentation of all of the following categories:

(i) Gait;

(ii) Spine (deformities, range of motion, palpation);

(iii) Hips and sacroiliac joints;

(iv) Motor;

(v) Sensation;

(vi) Reflexes;

(vii) Upper motor neuron signs.

(c) Diagnostic testing.

(i) Lumbar X-rays (including flexion and extension views) and a lumbar MRI or lumbar CT (with or without myelography) must be performed;

(ii) Electromyography (EMG) / nerve conduction study (NCS) may be performed if questions still remain during surgical planning.

(d) Discussion and consideration of opportunities for vocational rehabilitation.

(e) Review of current and previous medications taken.

(i) If opioid management is in process, review for best practices;

(ii) Consider impact of surgery on opioid load.

(f) Health behavioral assessment (pre-surgical).

Biopsychosocial factors that may affect treatment of the injured worker's allowed lumbar conditions are considered modifiable conditions that may change the need for surgery or improve surgical outcomes if appropriately addressed, and must be addressed if identified in the assessment. The health behavioral assessment and any identified interventions may be ordered by the injured worker's physician of record or treating physician, or the operating surgeon.

(g) Accounting and assessment of the following co-morbidities to stratify additional associated risks:

(i) Smoking;

(ii) Body mass index (BMI);

(iii) Diabetes;

(iv) Coronary artery disease;

(v) Peripheral vascular disease.

The co-morbidities indicated above are considered modifiable conditions that may improve surgical outcomes if appropriately addressed, and must be addressed if identified in the assessment.

(h) The injured worker and the physician of record, the treating physician, or the operating surgeon must have reviewed and signed the educational document, "What BWC Wants You to Know About Lumbar Fusion Surgery," attached as an appendix to this rule.

(4) The prerequisites to consideration of lumbar fusion surgery set forth in paragraphs (A)(1) to (A)(3) of this rule may be waived in cases of:

(a) Progressive functional neurological deficit;

(b) Spinal fracture;

(c) Tumor;

(d) Infection;

(e) Trauma care;

(f) Emergency as defined in rule 4123-6-01 of the Administrative Code; and/or

(g) Other catastrophic spinal pathology causally related to the injured worker's allowed conditions.

(B) Authorization for lumbar fusion surgery where the injured worker has no prior history of lumbar surgery at the level for which the fusion is requested.

(1) Authorization for lumbar fusion shall be considered in cases where the injured worker has no prior history of lumbar surgery only when the injured worker remains highly functionally impaired despite a trial of at least sixty days of conservative care as provided in paragraph (A)(1)(a) of this rule (unless waived pursuant to paragraph (A)(4) of this rule) and one or more of the following are present:

(a) Mechanical low back pain with instability of the lumbar segment and no history of lumbar surgery.

(b) Spondylolisthesis of twenty-five per cent or more with one or more of the following:

(i) Objective signs/symptoms of neurogenic claudication;

(ii) Objective signs/symptoms of unilateral or bilateral radiculopathy, which are corroborated by neurologic examination and by MRI or CT (with or without myelography);

(iii) Instability of the lumbar segment.

(c) Lumbar radiculopathy with stenosis and bilateral spondylolysis.

(d) Lumbar stenosis necessitating decompression in which facetectomy of greater than or equal to fifty per cent or more is required.

(e) Primary neurogenic claudication and/or radiculopathy associated with lumbar spinal stenosis in conjunction with spondylolisthesis or lateral translation of three mm or greater or bilateral pars defect.

(f) Degenerative disc disease (DDD) associated with significant instability of the lumbar segment.

(g) Spinal stenosis, disc herniation, or other neural compressive lesion requiring extensive, radical decompression with removal of greater than fifty per cent of total facet volume at the associated level.

The surgeon must document why the surgical lesion would require radical decompression through the pars interarticularis (critical stenosis, recurrent stenosis with extensive scarring, far lateral lesion).

(2) For purposes of this paragraph, instability of the lumbar segment is defined as at least four mm of anterior/posterior translation at L3-4 and L4-5, or five mm of translation at L5-S1, or eleven degrees greater end plate angular change at a single level, compared to an adjacent level.

(C) Request for lumbar fusion surgery where the injured worker has a history of prior lumbar surgery at the level for which the fusion is requested.

(1) If a trial of at least sixty days of conservative care as provided in paragraph (A)(1)(a) of this rule has failed to relieve symptoms (or has been waived pursuant to paragraph (A)(4) of this rule) and the injured worker has had a prior laminectomy, discectomy, or other decompressive procedure at the same level, lumbar fusion should be considered for approval only if the injured worker has one or more of the following:

(a) Mechanical (non-radicular) low back pain with instability at the same or adjacent levels.

(b) Mechanical (non-radicular) low back pain with pseudospondylolisthesis, rotational deformity, or other condition leading to a progressive, measureable deformity.

(c) Objective signs/symptoms compatible with neurogenic claudication or lumbar radiculopathy that is supported by EMG/NCS, lumbar MRI, or CT and detailed by a clinical neurological examination in the presence of instability of three mm lateral translation with at least two prior decompression surgeries at the same level.

(d) Evidence from post laminectomy structural study of either:

(i) One hundred per cent loss of facet surface area unilaterally; or

(ii) Fifty per cent combined loss of facet surface area bilaterally.

(e) Documented pseudoarthrosis or nonunion, with or without failed hardware, in the absence of other neural compressive lesion.

(2) For purposes of this paragraph, instability of the lumbar segment is defined as at least four mm of anterior/posterior translation at L3-4 and L4-5, or five mm of translation at L5-S1, or eleven degrees greater end plate angular change at a single level, compared to an adjacent level.

(D) Lumber fusion surgical after care.

The physician of record or treating physician must follow the injured worker until the injured worker has reached maximum medical improvement (MMI) for the allowed lumbar conditions.

The operating surgeon must follow the injured worker until the injured worker has reached a plateau relative to the lumbar fusion and the surgeon has determined no further surgical related treatment is medically necessary.

(1) In the first six months post-operatively, the injured worker must be seen by both the physician of record or treating physician and the operating surgeon at least every two months to monitor the injured worker's progress, rehabilitation needs, behavioral patterns or changes, and return to work willingness and/or status.

During this period, the physician of record or treating physician and the operating surgeon shall determine the following:

(a) Fusion status;

(b) Pain and functional status;

(c) MMI status of injured worker;

(d) Residual level of functional capacity;

(e) Appropriateness for vocational rehabilitation.

(2) From six months to one year post-operatively, if the injured worker continues to experience significant functional impairment despite the lumbar fusion, the following actions are recommended:

(a) Pain and functional status (repeat VAS / pain diagram / Oswestry)

(b) Repeat baseline orthopedic / neurological examination;

(c) Repeat health behavioral assessment;

(d) Revisit appropriate diagnostic imaging.

(e) Coordinate with MCO to develop a plan of care / return to functional status.

Last updated February 1, 2022 at 9:36 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 2/1/2027
Rule 4123-6-33 | Payment for health and behavior assessment and intervention services.
 

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 worker has the capacity to understand and respond meaningfully during the health behavior assessment process and:

(1) The injured worker's physician of record determines:

(a) The injured worker is not progressing with their injury after the initial course of treatment; and

(b) The injured worker's healing appears to be delayed due to behavioral barriers; or

(2) The injured worker is being evaluated by the physician of record, treating physician or operating surgeon for lumbar fusion surgery pursuant to rule 4123-6-32 of the Administrative Code.

References in this rule to "physician of record" shall also include the "treating physician or operating surgeon" with regard to HBAI services requested or performed in connection with lumbar fusion surgery pursuant to rule 4123-6-32 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 of the request, for the services being requested:

(1) Provider types who are eligible to bill evaluation and management codes must utilize evaluation and management codes when billing for HBAI services;

(2) Provider types who are not eligible to bill evaluation and management codes must utilize the applicable HBAI service codes when billing for HBAI services;

(3) HBAI services must be directed toward, and billed with, the injured worker's allowed physical condition(s);

(4) The bureau of workers' compensation shall not reimburse any HBAI services rendered to diagnose or treat psychological conditions, as the focus of these services is not on mental health but on factors impacting the prevention, treatment, or management of physical health problems and treatments.

(C) Health behavior assessment services.

(1) The physician of record requesting a health behavior assessment must submit a medical treatment reimbursement request for the assessment (on form C-9 or equivalent) to the injured worker's MCO.

(2) The physician of record must document the following to support the request for the assessment:

(a) History of the industrial injury or occupational disease resulting in the allowed conditions in the claim;

(b) Recognized behavioral barriers impeding the injured worker's recovery from the allowed conditions in the claim;

(c) Documentation of the initial course of treatment, including all treatment and diagnostic studies as of the date of the request, including all results;

(d) The assessment is not duplicative of other provider assessments.

(3) The health behavior assessment may be performed by any provider whose professional scope of practice as defined under state law includes health behavior assessment services.

(4) The provider conducting the health behavior assessment must provide a written summary report to the physician of record indicating the findings of the assessment and appropriate recommendations for intervention services, if any. The report shall include at a minimum the following:

(a) History of the industrial injury or occupational disease resulting in the allowed conditions in the claim;

(b) Overview of treatment and diagnostic studies to date and results;

(c) Use of one or more currently accepted and validated screening tools;

(d) Assessment conclusions/findings including, at a minimum:

(i) Identification and/or validation of existence of behavioral barriers;

(ii) A statement as to whether the injured worker's healing or recovery progress from the allowed conditions is impeded by the identified behavioral barriers;

(iii) Recommendation of possible intervention services and goals to address the identified behavioral barriers; and

(iv) The expected duration of the recommended intervention services;

(5) Except as otherwise provided in rule 4123-6-32 of the Administrative Code, only one health behavior assessment per year may be approved for an injured worker.

(6) Health behavior re-assessment services.

(a) One re-assessment per year may be approved for an injured worker who has undergone health behavior intervention services.

(b) A physician of record requesting a re-assessment must:

(i) Submit a medical treatment reimbursement request for the reassessment (on form C-9 or equivalent) to the injured worker's MCO; and

(ii) Provide clear rationale for why a re-assessment is required, including new and changed circumstances in the injured worker's physical status.

(7) The provider conducting the health behavior assessment or re-assessment of an injured worker may not provide health behavior intervention services for the same injured worker.

(D) Health behavior intervention services.

(1) After review of the assessment, the physician of record shall:

(a) Determine the medically necessary and appropriate health behavior intervention services to be provided; and

(b) Submit a medical treatment reimbursement request for the services (on form C-9 or equivalent) to the injured worker's MCO.

(2) The health behavior intervention services may be performed by any provider whose professional scope of practice as defined under state law includes health behavior intervention services.

(3) Health behavior intervention services are limited to coaching and counseling services that address the behavioral barriers identified or validated in the assessment.

(4) Documentation for each intervention encounter must include the following:

(a) Goals;

(b) Progress, or lack thereof, toward goals and objectives;

(c) Description of injured worker engagement; and

(d) Time in and time out and duration of services.

(5) Health behavior intervention services shall be limited to up to six hours in a twelve month period. Additional intervention services may be approved during the twelve month period, if the physician of record provides documentation the additional services are medically necessary.

Last updated February 1, 2022 at 9:36 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4131.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 2/1/2027
Prior Effective Dates: 7/1/2018
Rule 4123-6-34 | Payment for treatment of concussion injuries.
 

This rule governs the bureau's reimbursement for services in an allowed claim related to concussion. It is not meant to preclude, 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 twist in the skull, causing chemical changes in the brain and sometimes stretching and damaging brain cells.

(1) Concussion is manifest by at least one of the following:

(a) Any alteration in mental state at the time of the accident (feeling dazed, disoriented, or confused);

(b) Any period of loss of consciousness;

(c) Any loss of memory for events immediately before or after the accident; or

(d) Focal neurological deficit that may or may not be transient, but where the severity of the injury does not exceed the following:

(i) A loss of consciousness for approximately thirty minutes or less;

(ii) After thirty minutes, an initial "Glasgow Coma Score" of 13-15; or

(iii) Post-traumatic amnesia not greater than twenty-four hours.

(2) A concussion may involve different symptoms, clinical profiles and subtypes, and different recovery trajectories, which may be influenced by a variety of risk factors. Kontos, Anthony P. and Michael W. Collins. Concussion: a clinical profile approach to assessment and treatment. Washington, DC: American psychological association (2018), p.5. Adapted with permission.

(3) In concussion, even though by definition brain injury has occurred, standard imaging studies such as CT scan and MRI will commonly be normal.

(B) As used in this rule, "clinical domains" related to concussion means the following group of signs or symptoms related to a specific body part or system:

(1) Anxiety and mood: including ruminating thoughts, difficulty concentrating, hypervigilance, or fastidiousness.

(2) Vestibular: including impaired balance and equilibrium, dizziness, nausea, or environmental sensitivity,

(3) Ocular: including impaired vision and visual tracking, impaired comprehension, trouble focusing, or distractibility.

(4) Sleep: including trouble falling asleep or sleeping more or less than usual.

(5) Cervical: including neck pain, stiffness, or reduced range of motion.

(6) Cognitive fatigue: including impaired thinking abilities, feeling slow or "one step behind", physical and mental fatigue, general headache, or sleep disturbance.

(7) Headache (migraine, cervicogenic, and tension headache): including variable and intermittent severe headache, nausea, photosensitivity, or vestibular migraine.

(8) Cognitive impairment: including impairment in attention, memory, executive function, language processing, or visual perception and processing.

(C) Notwithstanding any provision to the contrary in any other rule of the bureau, medical treatment reimbursement requests relating to the clinical domains set forth in paragraph (B) of this rule, submitted within six months from the date of injury, for treatment not to exceed six months from the date of injury, may be authorized in an allowed claim, without disclaimer, when:

(1) The documented mechanism of injury in the claim included a bump or blow to the head, or a jolt or hit to the body: and

(2) Signs or symptoms related to the clinical domains have manifested within six weeks of the date of injury; and

(3) The requested medical treatment is determined to be medically necessary and appropriate, and reasonably related to treatment of concussion, based on the medical evidence.

(D) When concussion or other conditions relating to the clinical domains set forth in paragraph (B) of this rule and treated pursuant to paragraph (C) of this rule are determined to require ongoing treatment beyond six months, the physician of record or treating provider may request these conditions be additionally allowed in the claim.

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 1/1/2025
Rule 4123-6-35 | Payment for spinal cord stimulator.
 

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 to preclude, or substitute for, the treating physician's responsibility to exercise sound clinical judgment in light of current best medical practices when treating injured workers.

A provider's failure to comply with this rule may constitute endangerment to the health and safety of injured workers, and claims involving a spinal cord stimulator 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 4123-6-22 of the Administrative Code or other peer review committee established by the bureau.

Medical treatment reimbursement requests (on form C-9 or equivalent) for a spinal cord stimulator are not subject to dismissal by the MCO pursuant to paragraph (F)(7) of rule 4123-6-16.2 of the Administrative Code.

(A) Authorization for a spinal cord stimulator will be considered only in cases in which the following criteria are met:

(1) Allowed conditions. The injured worker has one or more of the following conditions allowed in their claim:

(a) Failed thoracic or lumbar spinal surgery.

(b) Complex regional pain syndrome.

(c) Non-operable peripheral vascular disease/limb ischemia.

(d) Neuropathic pain post-thoracic or post-lumbar surgery.

(e) Chronic thoracic or lumbar radiculopathy.

(f) Spinal cord injury dysesthesias.

(2) Conservative care. The injured worker has undergone at least sixty days of conservative care, which may include but is not limited to:

(a) Anti-inflammatory medication(s) treatment;

(b) Chiropractic or osteopathic treatment;

(c) Epidural steroid injection therapy;

(d) Pain management program participation;

(e) Physical medicine rehabilitation program participation; or

(f) Physical therapy.

(3) Surgeon evaluation. The injured worker has been personally evaluated by the operating surgeon and undergone a comprehensive evaluation, in which all of the following have been documented:

(a) Date of injury;

(b) Mechanism of injury;

(c) Past medical history, including:

(i) Prior surgeries;

(ii) List of current medical and psychological conditions;

(iii) List of current medications;

(iv) List of drug allergies.

(d) Physical examination;

(e) Pertinent neurological and vascular testing;

(f) Completion of a health behavioral assessment and, when appropriate, identified intervention services;

(g) Consideration of vocational rehabilitation services.

(4) Education. The injured worker and physician of record, treating physician, or operating surgeon have reviewed and signed the educational document, "What BWC Wants You to Know About Spinal Cord Stimulators," attached as an appendix to this rule.

(5) Spinal cord stimulator trial. Having met the criteria outlined in paragraphs (A)(1) to (A)(4) of this rule, and prior to implantation of a spinal cord stimulator, the injured worker has completed an approved seven-day spinal cord stimulator trial, with documented improvement in a majority of the following areas:

(a) Activities of daily living, documented through use of an evidence-based tool (e.g., "OSWESTRY Disability Index Questionnaire or Roland Morris Disability Questionnaire");

(b) Gait;

(c) Mood and affect;

(d) Pain level, documented through use of an evidence-based pain scale (e.g., visual analog scale) and a decrease of use of the morphine equivalent dosage of any pre-procedure opioid analgesic; and

(e) Sleep.

(B) BWC will not reimburse for a spinal cord stimulator:

(1) For the treatment of failed cervical spine surgery, neuropathic pain post-cervical surgery, or cervical radiculopathy;

(2) When the injured worker has an implanted pacemaker or defibrillator, metabolic or alcoholic neuropathy, or somatization disorder; or

(3) When any of the following documented conditions are uncontrolled or untreated:

(a) Substance use disorder;

(b) Psychosis; or

(c) Bipolar disorder.

Last updated September 1, 2022 at 8:29 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 2/1/2027
Rule 4123-6-36 | Enhanced care program.
 

This rule governs the bureau's enhanced care program for injured workers who have sustained a compensable knee injury. The program is designed to simplify the claims management process and encourage higher quality, better coordinated care for eligible claims that results in improved outcomes.

(A) Notwithstanding any provision to the contrary in any other rule of the bureau, the administrator may, for purposes of the enhanced care program, allow one or more managed care organizations to authorize medical treatment reimbursement requests for the first sixty days from the initial allowance of an eligible claim for any conditions within the same knee as the conditions initially allowed in the claim, and presumed to be causally related to the same industrial injury or occupational disease, without disclaimer, during such time as the conditions for which treatment reimbursement is authorized but which are not yet allowed are being considered for allowance or being adjudicated.

(B) Claims meeting the following criteria are eligible for inclusion in the enhanced care program:

(1) The injured worker's claim is a work-related knee only injury as documented by the medical evidence in the claim, and is allowed for knee conditions only;

(2) The injured worker's physician of record is certified to participate in the HPP, and has signed and agrees to 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 of the Revised Code.

(C) The operation of the enhanced care program does not impair in any manner the right of an employer, injured worker, or their representatives to appeal a claim, additional allowance, or medical treatment reimbursement determination under section 4123.511 of the Revised Code or rule 4123-6-16 of the Administrative Code. However, if the employer, injured worker, or their representatives exercises its right to appeal a claim, additional allowance, or medical treatment reimbursement determination, the claim will be removed from the enhanced care program.

Last updated January 3, 2023 at 9:45 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4123.66
Amplifies: 4121.12, 4121.121, 4121.441
Five Year Review Date: 2/1/2027
Rule 4123-6-37 | Payment of hospital bills.
 

(A) Direct reimbursement will not be made to members of a hospital resident staff.

(B) Payment for personal comfort items, which include, but are not limited to, telephones, television, and private rooms provided at the patient's request, are not compensable.

(C) Bureau fees for hospital inpatient services.

(1) Bureau fees for hospital inpatient services will be based on usual and customary methods of payment, such as prospective payment systems, including diagnosis related groups (DRG), per diem rates, rates based on hospital cost to charge ratios or percent of allowed charges.

(2) Except in cases of emergency, prior authorization must be obtained in advance of all hospitalizations. The hospital must notify the bureau, the injured worker's MCO, QHP, or self-insuring employer of emergency inpatient admissions within one business day of the admission. Failure to comply with this rule shall be sufficient ground for denial of room and board charges by the bureau, MCO, QHP, or self-insuring employer from the date of admission up to the actual date of notification. Room and board charges denied pursuant to this rule may not be billed to the injured worker.

(D) Bureau fees for hospital outpatient services.

(1) Bureau fees for hospital outpatient services, including emergency services, will be reimbursed in accordance with usual and customary methods of payment which may include prospectively determined rates, allowable fee maximums, ambulatory payment categories (APC), hospital cost to charge ratios, or a percent of allowed charges, as determined by the bureau.

(2) Treatment in the emergency room of a hospital must be of an immediate nature to constitute an emergency as defined in this chapter. Prior authorization of such treatment is not required. However, in situations where the emergency room is being utilized to deliver non-emergency care, notification will be provided to the 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.

Last updated February 1, 2022 at 9:37 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: : 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 2/1/2027
Rule 4123-6-37.1 | Payment of hospital inpatient services.
 

(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, 2024 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 (A)(4) of this rule, or acute or subacute inpatient detoxification services subject to reimbursement on a per diem basis under paragraph (A)(7) of this rule, will be calculated using the applicable medicare severity diagnosis related group (MS-DRG) reimbursement rate for the hospital inpatient service under the medicare inpatient prospective payment system multiplied by a payment adjustment factor of 1.181 plus a new technology add-on payment (if applicable), according to the following formula:

MS-DRG reimbursement rate x 1.181 + new technology add-on payment (if applicable) = bureau reimbursement for hospital inpatient service.

(b) In the event the centers for medicare and medicaid services makes subsequent adjustments to the medicare reimbursement rates under the medicare inpatient prospective payment system as implemented by the materials specified in paragraph (A)(10) of this rule other than technical corrections, including but not limited to adjustments related to federal budget sequestration pursuant to the Budget Control Act of 2011, 125 Stat. 239, 2 U.S.C. 900 to 907d as amended as of the effective date of this rule, the "applicable medicare severity diagnosis related group (MS-DRG) reimbursement rate for the hospital inpatient service under the medicare inpatient prospective payment system" as specified in this paragraph will be determined by the bureau without regard to such subsequent adjustments.

(2) In addition to the payment specified by paragraph (A)(1) of this rule, hospitals operating approved graduate medical education programs and receiving additional reimbursement from medicare for costs associated with these programs will receive an additional per diem amount for direct graduate medical education costs associated with hospital inpatient services reimbursed by the bureau. Hospital specific per diem rates for direct graduate medical education will be calculated annually by the bureau effective February first of each year, using the most current cost report data available from the centers for medicare and medicaid services, according to the following formula:

1.181 x [(total approved amount for resident cost + total approved amount for allied health cost)/ total inpatient days] = direct graduate medical education per diem.

Direct graduate medical education per diems will not be applied to outliers as defined in paragraph (A)(3) of this rule, services provided by hospitals subject to reimbursement under paragraph (A)(4) of this rule, or acute or subacute inpatient detoxification services subject to reimbursement on a per diem basis under paragraph (A)(7) of this rule.

(3)

(a) Reimbursement for outliers as determined by medicare's inpatient prospective payment system outlier methodology will be calculated using the applicable medicare severity diagnosis related group (MS-DRG) reimbursement rate for the hospital inpatient service under the medicare inpatient prospective payment system multiplied by a payment adjustment factor of 1.181 plus the applicable medicare operating outlier amount and medicare capital outlier amount plus a new technology add-on payment (if applicable), according to the following formula:

(MS-DRG reimbursement rate x 1.181) + medicare operating outlier amount + medicare capital outlier amount + new technology add-on payment (if applicable) = bureau reimbursement for hospital inpatient service outlier.

(b) In the event the centers for medicare and medicaid services makes subsequent adjustments to the medicare reimbursement rates under the medicare inpatient prospective payment system as implemented by the materials specified in paragraph (A)(10) of this rule other than technical corrections, including but not limited to adjustments related to federal budget sequestration pursuant to the Budget Control Act of 2011, 125 Stat. 239, 2 U.S.C. 900 to 907d as amended as of the effective date of this rule, the "applicable medicare severity diagnosis related group (MS-DRG) reimbursement rate for the hospital inpatient service under the medicare inpatient prospective payment system" as specified in this paragraph will be determined by the bureau without regard to such subsequent adjustments.

(4) Reimbursement for inpatient services provided by hospitals and distinct-part units of hospitals designated by the medicare program as exempt from the medicare inpatient prospective payment system will be determined as follows:

(a) For hospitals the department of health and human services, centers for medicare and medicaid services maintains hospital-specific cost-to-charge ratio information on, reimbursement will be equal to the hospital's allowable billed charges multiplied by the hospital's reported operating cost-to-charge ratio information referenced in paragraph (A)(10)(c) of this rule multiplied by a payment adjustment factor of 1.14, not to exceed seventy per cent of the hospital's allowed billed charges.

(b) For hospitals the department of health and human services, centers for medicare and medicaid services does not maintain hospital-specific cost-to-charge ratio information on, reimbursement will be equal to the hospital's allowable billed charges multiplied by the applicable fiscal year 2024 urban or rural statewide average operating cost-to-charge ratio set forth in table 8A of the federal rule referenced in paragraph (A)(10)(b) of this rule (the Ohio average operating cost-to-charge ratio will be used for hospitals outside the United States) multiplied by a payment adjustment factor of 1.14, not to exceed seventy per cent of the hospital's allowed billed charges.

(5) Reimbursement for inpatient services provided by hospitals and distinct-part units of hospitals that do not participate in the medicare program will be calculated in accordance with the applicable provisions of paragraphs (A)(1) and (A)(3) of this rule using the national standardized amount for fiscal year 2024, full update, as found at 88 Fed. Reg. 59356 (2023).

(6) Reimbursement for inpatient services provided by "new hospitals" as defined in 42 C.F.R. 412.300(b) as published in the October 1, 2023 Code of Federal Regulations will be calculated in the same manner as provided under paragraph (A)(4)(b) of this rule.

(7) Reimbursement for acute or subacute inpatient detoxification services will be calculated in accordance with the applicable provisions of paragraph (A) of this rule, unless the hospital elects to be reimbursed for these services on a per diem basis, in which case the hospital will be reimbursed the lesser of the charges billed by the hospital for the allowed services rendered, the all-inclusive per diem rates set forth in Table 1 of the appendix to this rule, or the rate the MCO contracted or negotiated with the hospital.

(8) Except for services subject to reimbursement on a per diem basis under paragraph (A)(7) of this rule, if the MCO has contracted or negotiated a different payment rate with a hospital pursuant to rule 4123-6-10 of the Administrative Code, reimbursement will be at the contracted or negotiated rate.

(9) For purposes of this rule, hospitals must report the applicable inpatient revenue codes for accommodation and ancillary services set forth in Table 2 of the appendix to this rule.

(10) For purposes of this rule, the "medicare severity diagnosis related group (MS-DRG) reimbursement rate," "medicare operating outlier amount," "medicare capital outlier amount," and "new technology add-on payment" will be determined in accordance with the medicare program established under Title XVIII of the Social Security Act, 79 Stat. 286 (1965), 42 U.S.C. 1395 to 1395lll as amended as of the effective date of this rule, excluding 42 U.S.C. 1395ww(m), as implemented by the following materials, which are incorporated by reference:

(a) 42 C.F.R. Part 412 as published in the October 1, 2023 Code of Federal Regulations;

(b) Department of health and human services, centers for medicare and medicaid services' "42 CFR Parts 411, 412, 419, 488, 489 and 495 medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and policy changes and fiscal year 2024 rates; quality programs and medicare promoting interoperability program requirements for eligible hospitals and critical access hospitals; rural emergency hospital and physician-owned hospital requirements; and provider and supplier disclosure of ownership; and medicare disproportionate share hospital (DSH) payments: counting certain days associated with section 1115 demonstrations in the medicaid fraction final rule," 88 Fed. Reg. 58640 - 59438 (2023).

(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 2023 update to the department of health and human services, centers for medicare 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 maintains hospital-specific cost-to-charge ratio information on, the hospital's allowable billed charges multiplied by the hospital's reported operating cost-to-charge ratio information referenced in paragraph (A)(10)(c) of this rule multiplied by a payment adjustment factor of 1.14, not to exceed seventy per cent of the hospital's allowed billed charges;

(b) For hospitals the department of health and human services, centers for medicare and medicaid services does not maintain hospital-specific cost-to-charge ratio information on, the hospital's allowable billed charges multiplied by the applicable fiscal year 2024 urban or rural statewide average operating cost-to-charge ratio set forth in table 8A of the federal rule referenced in paragraph (A)(10)(b) of this rule (the Ohio average operating cost-to-charge ratio will be used for hospitals outside the United States) multiplied by a payment adjustment factor of 1.14, not to exceed seventy per cent of the hospital's allowed billed charges; or

(3) The rate negotiated between the hospital and the QHP or self-insuring employer in accordance with rule 4123-6-46 of the Administrative Code.

View Appendix

Last updated November 1, 2024 at 8:45 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 1/1/2025
Prior Effective Dates: 2/1/2011, 2/1/2014, 2/1/2017, 2/1/2019, 2/1/2020
Rule 4123-6-37.2 | Payment of hospital outpatient services.
 

(A) HPP:

Unless an MCO has negotiated a different payment rate with a hospital pursuant to rule 4123-6-10 of the Administrative Code, reimbursement for hospital outpatient services with a date of service of May 1, 2024 or after will be the applicable rate set forth in this rule as follows:

(1) Except as otherwise provided in this rule, reimbursement for hospital outpatient services will be equal to the applicable medicare reimbursement rate for the hospital outpatient service under the medicare outpatient prospective payment system as implemented by the materials specified in paragraph (A)(10) of this rule, multiplied by a bureau-specific payment adjustment factor, which will be 2.758 for children's hospitals and 1.485 for all hospitals other than children's hospitals, plus the add-on payments set forth in paragraph (A)(4) of this rule, if applicable.

BWC will use the medicare integrated outpatient code editor and medicare medically unlikely edits in effect as implemented by the materials specified in paragraph (A)(9) of this rule and table 8 of the appendix to this rule to process bills for hospital outpatient services under this rule; however, BWC will not apply the outpatient code edits identified in table 1 of the appendix to this rule.

BWC will not apply the annual medicare outpatient prospective payment system outlier, hold harmless, and exempt cancer hospital reconciliation processes to payments for hospital outpatient services under this rule.

For purposes of this rule, hospitals are identified as critical access hospitals, rural sole community hospitals, essential access community hospitals and exempt cancer hospitals based on the hospitals' 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 rainbow babies and children's hospital (Cleveland), Toledo children's hospital, children's hospital medical center of Akron, and children's medical center of Dayton.

Reimbursement for any hospital outpatient services identified in table 6 of the appendix to this rule will be determined using the medicare outpatient prospective payment system methodology as set forth in this paragraph, applying the status indicator and ambulatory payment classification specified for the service in table 6 of the appendix to this rule.

In the event the centers for medicare and medicaid services makes subsequent adjustments to the medicare reimbursement rates under the medicare outpatient prospective payment system as implemented by the materials specified in paragraph (A)(10) of this rule, other than technical corrections, including but not limited to adjustments related to federal budget sequestration pursuant to the Budget Control Act of 2011, 125 Stat. 239, 2 U.S.C. 900 to 907(d) as amended as of the effective date of this rule, the "applicable medicare reimbursement rate for the hospital outpatient service under the medicare outpatient prospective payment system" as specified in this paragraph will be determined by the bureau without regard to such subsequent adjustments.

(2) Services reimbursed via fee schedule. These services will not be wage index adjusted.

(a) Services reimbursed via fee schedule to which the bureau-specific payment adjustment factor will be applied.

Except as otherwise provided in paragraphs (A)(2)(b)(ii) and (A)(2)(b)(iii) of this rule, hospital outpatient services reimbursed via fee schedule under the medicare outpatient prospective payment system will be reimbursed under the applicable medicare fee schedule in effect as implemented by the materials specified in paragraph (A)(10) of this rule, plus the add-on payments set forth in paragraph (A)(4) of this rule, if applicable.

(b) Services reimbursed via fee schedule to which the bureau-specific payment adjustment factor will not be applied.

The following services will be reimbursed the lesser of the charges billed by the hospital for the allowed services rendered, the applicable fee schedule rates set forth in tables 2, 3, 4 and 5 of the appendix to this rule, or the rate the MCO contracted or negotiated with the hospital:

(i) Hospital outpatient vocational rehabilitation services for which the bureau has established a fee as set forth in table 2 of the appendix to this rule.

(ii) Hospital outpatient services reimbursed via fee schedule under the medicare outpatient prospective payment system that the bureau has determined will be reimbursed at a rate other than the applicable medicare fee schedule in effect as implemented by the materials specified in paragraph (A)(10) of this rule, for which the bureau has established a fee as set forth in table 3 of the appendix to this rule.

(iii) Hospital outpatient services not reimbursed under the medicare outpatient prospective payment system that the bureau has determined are necessary for treatment of injured workers, for which the bureau has established a fee as set forth in tables 4 and 5 of the appendix to this rule.

(3) Services reimbursed at reasonable cost. To calculate reasonable cost, the line item charge will be multiplied by the hospital's outpatient cost to charge ratio from the medicare outpatient provider specific file in effect as implemented by the materials specified in paragraph (A)(10) of this rule. These services will not be wage index adjusted.

(a) Services reimbursed at reasonable cost to which the bureau-specific payment adjustment factor will be applied.

Notwithstanding any other reimbursement methodology set forth in this rule, critical access hospitals will be reimbursed at one hundred one per cent of reasonable cost for all payable line items.

(b) Services reimbursed at reasonable cost to which the bureau-specific payment adjustment factor will not be applied.

(i) Services designated as inpatient only under the medicare outpatient prospective payment system.

(ii) Hospital outpatient services reimbursed at reasonable cost as identified in tables 3 and 4 of the appendix to this rule.

(4) Add-on payments calculated using the applicable medicare outpatient prospective payment system methodology and formula in effect as implemented by the materials specified in paragraph (A)(10) of this rule. These add-on payments will be applied after the application of the bureau-specific payment adjustment factor.

(a) Outlier add-on payment. An outlier add-on payment will be provided on a line item basis for partial hospitalization services and for ambulatory payment classification reimbursed services for all hospitals other than critical access hospitals.

(b) Rural hospital add-on payment. A rural hospital add-on payment will be provided on a line item basis for rural sole community hospitals, including essential access community hospitals; however, drugs, biological, devices reimbursed via pass-through and reasonable cost items will be excluded. The rural add-on payment will be calculated prior to the outlier add-on payment calculation.

(c) Hold harmless add-on payment. A hold harmless add-on payment will be provided on a line item basis to exempt cancer centers and children's hospitals. The hold harmless add-on payment will be calculated after the outlier add-on payment calculation.

(5) Providers not participating in the medicare program.

Reimbursement for outpatient services provided by hospitals and distinct-part units of hospitals that do not participate in the medicare program will be calculated in accordance with the methodologies set forth in this rule, using the applicable FY24 urban or rural statewide average outpatient cost-to-charge ratio adopted by the medicare program pursuant to the federal rule referenced in paragraph (A)(10)(b) of this rule (the Ohio average cost-to-charge ratio will be used for hospitals outside the United States).

(6) Reimbursement for outpatient services provided by "new hospitals" as defined in 42 C.F.R. 412.300(b) as published in the October 1, 2023 Code of Federal Regulations shall be calculated in the same manner as provided under paragraph (A)(5) of this rule.

(7) For purposes of this rule, hospitals are to report the applicable outpatient revenue codes for accommodation and ancillary services set forth in table 7 of the appendix to this rule.

(8) For purposes of this rule, coverage status for designated hospital outpatient services is set forth in table 9 of the appendix to this rule.

(9) For purposes of this rule, services subject to always and sometimes therapy editing are set forth in table 10 of the appendix to this rule.

(10) For purposes of this rule, the "applicable medicare reimbursement rate for the hospital outpatient service under the medicare outpatient prospective payment system " and the "medicare outpatient prospective payment system " will be determined in accordance with the medicare program established under Title XVIII of the Social Security Act, 79 Stat. 286 (1965), 42 U.S.C. 1395 to 1395lll as amended, as of the effective date of this rule, as implemented by the following materials, which are incorporated by reference:

(a) 42 C.F.R. Part 419 as published in the October 1, 2023 Code of Federal Regulations;

(b) Department of health and human services, centers for medicare and medicaid services' "42 CFR Parts 405, 410, 416, 419, 424, 485, 488, 489 Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems; Quality Reporting Programs; Payment for Intensive Outpatient Services in Hospital Outpatient Departments, Community Mental Health Centers, Rural Health Clinics, Federally Qualified Health Centers, and Opioid Treatment Programs; Hospital Price Transparency; Changes to Community Mental Health Centers Conditions of Participation, Proposed Changes to the Inpatient Prospective Payment System Medicare Code Editor; Rural Emergency Hospital Conditions of Participation Technical Correction" final rule 88 Fed. Reg. 81540 - 82185 (2023).

(c) The department of health and human services, centers for medicare and medicaid services' hospital-specific cost-to-charge ratio information as of the October 2023 update to the department of health and human services, centers for medicare and medicaid services' outpatient-provider specific file (OPSF).

(B) QHP or self-insuring employer (non-QHP):

A QHP or self-insuring employer may reimburse hospital outpatient services at:

(1) The applicable rate under the methodology set forth in paragraph (A) of this rule; or

(a) For hospitals the department of health and human services, centers for medicare and medicaid services maintains hospital-specific cost-to-charge ratio information on, the hospital's allowable billed charges multiplied by the hospital's cost-to-charge ratio information referenced in paragraph (A)(10)(c) of this rule multiplied by a payment adjustment factor of 1.16, not to exceed sixty per cent of the hospital's allowed billed charges.

(b) For hospitals the department of health and human services, centers for medicare and medicaid services does not maintain hospital-specific cost-to-charge ratio information on the hospital's allowable billed charges multiplied by the applicable FY24 urban or rural statewide average outpatient cost-to-charge ratio adopted by the medicare program pursuant to the federal rule referenced in paragraph (A)(10)(b) of this rule (the Ohio average cost-to-charge ratio will be used for hospitals outside the United States) multiplied by a payment adjustment factor of 1.16, not to exceed sixty per cent of the hospital's allowed billed charges; or

(2) The rate negotiated between the hospital and the QHP or self-insuring employer in accordance with rule 4123-6-46 of the Administrative Code.

(C) Provider-based status

The bureau may request information from any facility billing the bureau for services as a provider-based facility as may be necessary to establish whether the facility meets the criteria for provider-based status under 42 C.F.R. 413.65 as published in the October 1, 2023 Code of Federal Regulations. The information requested may include an attestation by the facility.

View Appendix

Last updated July 24, 2024 at 4:18 PM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 5/1/2025
Prior Effective Dates: 9/1/2007, 4/1/2013, 5/1/2016, 5/1/2017, 5/16/2020, 5/6/2021, 5/1/2022
Rule 4123-6-37.3 | Payment of ambulatory surgical center services.
 

Unless an MCO has negotiated a different payment rate with an ambulatory surgical center pursuant to rule 4123-6-10 of the Administrative Code, reimbursement for ambulatory surgical center services with a date of service of May 1, 2024 or after will be equal to the lesser of the ambulatory surgical center's allowable billed charges or the fee schedule amount indicated in the appendix to this rule, developed with provider and employer input and effective May 1, 2024.

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 2024 full payment update under the CMS ambulatory surgical center quality reporting (ASCQR) program, established by 42 U.S.C. 1395l as in effect as of the effective date of this rule and 42 C.F.R. Part 416, Subpart H as published in the October 1, 2023 Code of Federal Regulations, will be subject to a two per cent reduction to the BWC 2024 ambulatory surgical center fee schedule amounts indicated in the appendix to this rule.

However, if such an ambulatory surgical center, upon reconsideration, is subsequently determined by CMS to meet quality measures for the calendar year 2024 full payment update under the CMS ASCQR program, upon the ambulatory surgical center's request the ambulatory surgical center will no longer be subject to the two per cent reduction, and the bureau will adjust any bills for dates of service on or after the effective date of this rule that were previously reduced pursuant to this rule.

View Appendix

Last updated May 9, 2024 at 8:40 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 5/1/2025
Prior Effective Dates: 4/1/2010, 5/5/2014, 5/1/2016, 5/1/2017, 5/16/2020, 5/6/2021, 5/1/2022
Rule 4123-6-38 | Payment for home health nursing services and home health aide services.
 

(A) Except as provided in rule 4123-6-38.1 of the Administrative Code, home health nursing services and home health aide services shall be provided by registered nurses or licensed practical nurses and home health aides employed by a home health agency meeting the qualifications specified in paragraph (C) of rule 4123-6-02.2 of the Administrative Code.

(B) Authorization for home health nursing services and home health aide services.

(1) Authorization for home health nursing services will be considered only in cases where, as the result of an allowed injury or occupational disease:

(a) The injured worker is mentally or physically incapable of independently performing activities of daily living; or

(b) Home health nursing services or home health aide services are ordered for discharge follow-up or by a treating physician as part of a written treatment plan.

(2) The request for authorization from the physician of record or treating physician must include a written treatment plan that identifies the reason for home health nursing services or home health aide services, the period of time the services will be needed, the specific services needed, and the number of hours per day that are needed.

(3) Authorization must be obtained prior to rendering home health nursing services or home health aide services, except in cases of emergency or where the injured worker's allowed conditions could be endangered by the delay of services.

(C) Except as otherwise provided in paragraph (D) of this rule, only part-time or intermittent home health nursing services or home health aide services will be authorized, in accordance with the written treatment plan. Part-time or intermittent care means that total home health nursing services and home health aide services do not exceed eight hours per day.

(D) When more than eight hours of total home health nursing services or home health aide services are medically necessary, the bureau will consider more appropriate alternative settings. In exceptional cases, the bureau may authorize more than eight hours of total home health nursing services or home health aide services when medically necessary and appropriate.

(E) Authorized home health aide services may include:

(1) Bathing, dressing, grooming, hygiene, including shaving, skin care, foot care, ear care, hair, nail, and oral care needed to facilitate care or prevent deterioration of the injured worker's health.

(2) Feeding, assistance with elimination including administering enemas (unless the skills of a home health nurse are necessary), routine catheter care, routine colostomy care, assistance with ambulation, changing position in bed, and assistance with transfers.

(3) Performing a selected nursing activity or task delegated in accordance with Chapter 4723-13 of the Administrative Code and performed as specified in the written treatment plan.

(4) Assisting with activities such as routine maintenance exercises and passive range of motion as specified in the written treatment plan developed by either a licensed therapist or a licensed registered nurse within their scope of practice. These activities are directly supportive of skilled therapy services but do not necessitate the skills of a therapist to be safely and effectively performed.

(5) Performing routine care of prosthetic and orthotic devices.

(F) Incidental services performed by a home health aide for the injured worker, such as laundry, minor meal preparation, or light housekeeping, are not direct health care services and will not be reimbursed, except to the extent they are ancillary to providing direct health care services. Incidental services may not extend the service hours provided, and may only be performed for the injured worker, not other members of the household.

(G) The services of an adult day care facility meeting the qualifications specified in paragraph (C) of rule 4123-6-02.2 of the Administrative Code may be utilized in lieu of home health nursing services or home health aide services. The hours of such adult day care facility services will be included in the calculation of service hours referenced in paragraph (C) of this rule.

(H) A physical examination of the injured worker must be conducted by the physician of record or treating physician no less than annually to ensure that home health nursing services or home health aide services, and the number of service hours requested, are medically necessary and appropriate as a result of the allowed injury or occupational disease. In extraordinary circumstances when an in-person physical examination is not reasonably possible, BWC may accept a telemedicine visit with the physician of record or treating physician.

(I) Home health agency providers must maintain records which fully document the extent of services provided to each injured worker, in compliance with rule 4123-6-45.1 of the Administrative Code. The bureau may request detailed hourly descriptions of care delivered to an injured worker to review care needs, medical necessity and appropriateness, and billing accuracy.

Last updated February 1, 2022 at 9:38 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 2/1/2027
Prior Effective Dates: 7/1/2013, 11/13/2015
Rule 4123-6-38.1 | Payment for nursing and caregiver services provided by persons other than home health agency employees.
 

(A) Nursing services provided prior to December 14, 1992.

(1) Registered nurses and licensed practical nurses who are not employed by a home health agency a home health agency certified in accordance with rule 4123-6-02.2 of the Administrative Code may continue to provide authorized services to an injured worker if the services began prior to December 14, 1992.

(2) The need for nursing services must be the result of an allowed injury or occupational disease.

(3) In the event the registered nurse or licensed practical nurse is no longer able to provide approved services or if services are stopped and later restarted, nursing services shall be provided only by an employee of a home health agency certified in accordance with rule 4123-6-02.2 of the Administrative Code.

(B) Non-licensed caregiver services.

(1) Requests for extension of non-licensed caregiver services initially provided prior to December 14, 1992.

(a) Prior to December 14, 1992, caregiver services provided by a non-licensed person including injured worker's spouse, friend or family member were considered for reimbursement in cases where the injured worker, as a result of an allowed injury or occupational disease, was bedfast, confined to a wheelchair, had a disability of two or more extremities which prevented the injured worker from caring for their own body needs or was otherwise unable to take care of their own bodily functions. Services include, but are not limited to, feeding, bathing, dressing, providing personal hygiene, and transferring from bed to chair. Household, personal or other duties related to maintaining a household, including but not limited to care or upkeep to the inside or outside of the residence, washing clothes, preparing meals, or running errands, are not considered nursing services, and will not be reimbursed, except to the extent such services are incidental to care of the injured worker.

(b) Requests for an extension of caregiver services initially approved prior to December 14, 1992, delivered by a non-licensed person, other than an attendant, aide, or injured worker's spouse, but including other family members or friends, will be approved only if:

(i) The injured worker does not have a spouse because the injured worker is not married, or the injured worker's spouse is deceased, or the claimant's spouse is physically or mentally incapable of caring for the injured worker; and,

(ii) The approved home health agency is greater than thirty-five miles from the injured worker's location and the home health agency refuses to provide services to the injured worker.

(c) In the event the caregiver is no longer able to provide approved services or if services are stopped and later restarted, services shall be provided only by an employee of a a home health agency certified in accordance with rule 4123-6-02.2 of the Administrative Code.

(2) Requests for extension of caregiver services initially provided on or after December 14, 1992 and prior to January 9, 1995.

(a) Requests for approval of caregiver services delivered by a non-licensed person, other than an attendant, aide, or injured worker's spouse were considered for reimbursement only if the injured worker did not have a spouse or the spouse was physically or mentally incapable of caring for the injured worker, or an approved home health agency was greater than thirty-five miles from the injured worker's location and the home health agency refused to provide services to the claimant.

(b) Criteria for approval of caregiver services were as indicated in paragraph (B)(1)(a) of this rule.

(c) After January 9, 1995, persons who are not home health agency home health aides or attendants, but who are currently approved to provide caregiver services to an injured worker, may continue to do so until services are no longer medically necessary or unless services are not authorized. After January 9, 1995, approval of caregiver services shall only be considered when services are rendered by a home health agency home health aide or attendant.

(d) In the event the caregiver is no longer able to provide approved services or if services are stopped and later restarted, services shall be provided only by an employee of a home health agency certified in accordance with rule 4123-6-02.2 of the Administrative Code.

(C) All covered home health services must comply with rule 4123-6-38 of the Administrative Code, except as otherwise provided in this rule.

(D) A review of the claim or assessment of the injured worker will be conducted at least annually to ensure that nursing or caregiver services are necessary as a result of the allowed injury or occupational disease.

Last updated February 1, 2022 at 9:38 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 2/1/2027
Prior Effective Dates: 2/14/2005
Rule 4123-6-38.2 | Payment of nursing home and residential care/assisted living services.
 

(A) Payment to a nursing home or residential care/assisted living facility for the care of an injured worker who sustained an injury or contracted an occupational disease in the course of and arising out of employment shall be made only when the need for such care is the direct result of the allowed conditions in the claim.

(B) Payment will be made only for care provided in nursing homes and residential care/assisted living facilities meeting the qualifications specified in paragraph (C) of rule 4123-6-02.2 of the Administrative Code.

(C) Nursing home or residential care/assisted living facility care must be pre-authorized, except when a nursing home or residential care/assisted living facility is used immediately following an approved or emergency hospitalization.

(1) The allowed per diem rate for an injured worker shall be no greater than the bureau's fee schedule or the rate negotiated between the nursing home or residential care/assisted living facility and the bureau, MCO, QHP, or self-insuring employer.

(2) Nursing home care shall be provided on a semiprivate bed basis, unless a situation exists when the use of a private room is medically necessary due to the allowed condition. In these cases, the use of such a private room must be pre-authorized, except in cases of emergency, as defined in rule 4123-6-01 of the Administrative Code, or where the injured worker's condition would be endangered by delay.

(3) Prescription medication provided to an injured worker in a nursing home for the treatment of an allowed injury or occupational disease is included in the nursing home's per diem rate, and is not separately payable.

Last updated February 1, 2022 at 9:38 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 2/1/2027
Prior Effective Dates: 7/1/2013
Rule 4123-6-39 | Payment for prosthetic device or other artificial appliances.
 

(A) For purposes of this rule:

(1) "Amputee clinic" means an 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 requiring prosthetic devices.

(2) "Artificial appliance" means any item that replaces a body part or function of a body part of an injured worker who has received a scheduled loss or facial disfigurement award for that body part under division (B) of section 4123.57 of the Revised Code, and that the amputee clinic at the Ohio state university medical center, the opportunities for Ohioans with disabilities agency, or a multidisciplinary amputee clinic or prescribing physician approved by the administrator or the administrator's designee determines is needed by the injured worker. Examples of artificial appliances include, but are not limited to, prosthetic devices, artificial eyes, wheelchairs, canes, crutches, walkers, braces, etc.

(3) "Prosthetic device" means a custom fabricated or fitted medical device that is a type of artificial appliance used to replace a missing appendage or other external body part. It includes an artificial limb, hand, or foot, but does not include devices implanted into the body by a physician, artificial eyes, intraocular lenses, dental appliances, ostomy products, cosmetic devices such as breast prostheses, eyelashes, wigs, or other devices that do not have a significant impact on the musculoskeletal functions of the body.

(B) In all cases arising under division (B) of section 4123.57 of the Revised Code, the bureau will pay the cost of purchasing or repairing an artificial appliance out of the surplus fund, regardless of whether the artificial appliance is part of the injured worker's vocational rehabilitation, or if the injured worker has, or will ever be able, to return to work, if an injured worker requires the purchase or repair of an artificial appliance as determined by any one of the following:

(1) The amputee clinic at the Ohio state university medical center;

(2) The opportunities for Ohioans with disabilities agency;

(3) A multidisciplinary amputee clinic or prescribing physician approved by the administrator or the administrator's designer.

(C) The bureau is responsible for processing requests for artificial appliance and travel expenses associated with the artificial appliance in all self-insured claims. When an artificial appliance is needed in a self-insured claim, the provider will send a request for the artificial appliance and/or request for repair, as well as the subsequent bills, to the bureau.

(D) It is the prosthetist's responsibility to ensure that any prosthetic device fits properly for three months from the date of dispensing. Any modifications, adjustments, or replacements within three months from the date of dispensing are the responsibility of the prosthetist who supplied the item and the bureau will not reimburse for those services. The provision of these services by another provider will not be separately reimbursed.

(E) Once payment for the artificial appliance has been made, replacement requests may be denied in instances of malicious damage, neglect, culpable irresponsibility, or wrongful disposition.

(F) The bureau will not pay the cost of purchasing or repairing a prosthetic device that is designed solely to enable the injured worker to engage in sports, hobbies, or other recreational activities.

Last updated February 1, 2022 at 9:39 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.57, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.57, 4123.66
Five Year Review Date: 2/1/2027
Prior Effective Dates: 2/14/2005
Rule 4123-6-40 | Payment of claimant travel expenses.
 

(A) An injured worker's reasonable and necessary travel expenses shall be paid, upon the filing of a proper request, under the following circumstances:

(1) When the injured worker has been ordered or authorized to undergo a medical examination outside of the city or community limits where he resides. The injured worker shall be reimbursed for travel only if the travel distance exceeds forty-five miles round trip.

(2) When treatment necessary for the allowed work related condition cannot be obtained within the city or community where the injured worker resides, and the treatment has been pre-authorized and approved. The injured worker shall be reimbursed for travel only if the travel distance exceeds forty-five miles round trip.

(3) When the injured worker's allowed conditions require taxicab or other special transportation for treatment or examination on account of an allowed injury or occupational disease. Taxicab or other special transportation must be pre-authorized.

(4) When travel expenses are authorized as part of an approved vocational rehabilitation assessment plan, comprehensive vocational rehabilitation plan, or job retention plan pursuant to rule 4123-18-08 of the Administrative Code.

(B) In situations described in paragraphs (A)(1), (A)(2), and (A)(4) of this rule, the injured worker will be reimbursed for the following:

(1) If the injured worker is traveling by automobile, mileage on a per mile basis if the mileage exceeds the distance established as provided under paragraph (A) of this rule, portal to portal, using the most direct and practical route;

(2) If the claimant is traveling by airplane, railroad or bus, the actual and necessary airplane, railroad or bus fare;

(3) The reasonable cost of necessary meals, based on distance traveled;

(4) Necessary lodging bills at reasonable actual cost. Lodging must be pre-authorized; and

(5) The actual and necessary cost of tolls and parking.

(C) When the injured worker has been requested to undergo a medical examination by a physician of the employer's choice, travel expenses incurred as a result of the examination are to be paid by the employer immediately upon the receipt of the bill. Payment of the bill shall not require an order of the bureau or commission, unless there is a dispute. The employer shall provide the injured worker with a proper form to be completed by the injured worker for reimbursement of traveling expenses. The minimum mileage provision of paragraphs (A)(1) and (A)(2) of this rule shall not apply for reimbursement of examinations under this paragraph (C) of this rule.

(D) The payment rates for meals, lodging, and travel are available at https://www.bwc.ohio.gov/downloads/blankpdf/C-60-A.pdf.

(E) This rule applies to all claims for work related injuries or occupational diseases, regardless of whether the employer is part of the state fund, is self-insuring, is non-complying, etc.

Last updated February 1, 2022 at 9:39 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 2/1/2027
Prior Effective Dates: 2/12/1997
Rule 4123-6-41 | No legal relationship between the industrial commission or bureau and a health care provider.
 

(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 worker are the legal obligation of the injured worker. The direct payment to the health care provider is a discretionary method by which the award made to the injured worker for medical expenses may be discharged.

(C) Except as prohibited by division (O) of section 4121.44 of the Revised Code, when payment is made to the injured worker, the sole legal recourse of the health care provider is against the injured worker.

Last updated February 1, 2022 at 9:40 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 2/1/2027
Prior Effective Dates: 1/1/1999, 11/13/2015
Rule 4123-6-42 | Interest on late payments for equipment, materials, goods, supplies or services in state insurance fund, public work relief employees' compensation fund, coal workers pneumoconiosis fund, and marine industry fund claims.
 

(A) Payment is made for equipment, materials, goods, supplies, or services incurred by the claimant in connection with claims against the state insurance fund, public work relief employees' compensation fund, coal workers pneumoconiosis fund, or marine industry fund in accordance with section 126.30 of the Revised Code. For the purpose of this rule, the required payment date is the date on which payment is due under the terms of a written agreement between 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 disease, employer's name, provider's name and address and assigned payee number, a description of the service provided, the procedure code for the service provided, the date provided, and the amount of the charge. If more than one item has been included in the invoice, each item is to be considered separately to determine if it is a proper invoice.

(2) If the bureau or its agent determines that an invoice is improper, the bureau or its agent shall send notification to the provider through the MCO at least fifteen days prior to what would be the required payment date if the invoice did not contain an error. The notice shall describe the error and the additional information needed to correct the error. The required payment date shall be redetermined upon receipt of a proper invoice.

(3) If an invoice is for payment of either a condition not allowed in a claim, or for a claim that is not allowed, the payment date is thirty days after final adjudication of allowance of the condition or claim. As defined in section 126.30 of the Revised Code, "final adjudication" is the date that the decision of the bureau, industrial commission, or court becomes final, with no further right of appeal. If any section of the Revised Code contains a faster timetable for payments, however, such provisions shall not be superseded by this rule.

(B) Interest shall be paid based on division (E) of section 126.30 of the Revised Code. Any interest charges payable under section 126.30 of the Revised Code are to be paid by the bureau of workers' compensation.

Last updated May 31, 2023 at 11:04 AM

Supplemental Information

Authorized By: 4121.12, 4121.30, 4121.31, 4123.05
Amplifies: 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 11/1/2026
Prior Effective Dates: 2/12/1997
Rule 4123-6-43 | Payment for transcutaneous electrical nerve stimulators and neuromuscular electrical stimulators.
 

(A) Payment will be approved for a transcutaneous electric nerve stimulator (TENS) unit for treatment of allowed conditions in a claim resulting from an allowed work related injury or occupational disease, as provided in this rule.

(1) Prior authorization is required for TENS units and supplies. An injured worker shall be provided only one TENS unit at a time. For each TENS unit request approved, the unit shall be rented for a thirty day trial period before purchase of the TENS unit. This trial period is to evaluate the medical necessity and effectiveness of the TENS treatment. TENS treatment will be discontinued at the end of the thirty day trial period where the treatment has not proven to be medically necessary or effective. Reimbursement of rental costs will be considered only for that portion of the trial period that the TENS unit was actually used if treatment was discontinued early. For each TENS unit provided, payment shall be limited to necessary disposable or rechargeable batteries, but not both.

(2) The bureau shall apply all rental payments previously made to the purchase price of the TENS unit. A TENS unit purchased and furnished to the injured worker is not the personal property of the injured worker, but remains the property of the bureau or self-insuring employer. The bureau or self-insuring employer reserves the right to reclaim and recover the TENS unit from the injured worker at the completion of the course of TENS treatment. Once a TENS unit is purchased, the bureau or self-insuring employer will reimburse for repair or replacement of the unit upon submission of a request from 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 sell or rent home medical equipment.

(B) The injured worker's MCO shall regularly determine the specific TENS supplies needed by the injured worker throughout the period of time authorized for TENS use. The TENS provider must receive authorization from the injured worker's MCO prior to the delivery of supplies and/or equipment. The TENS provider shall then deliver the supplies and bill the injured worker's MCO after authorization is received. A self-insuring employer may, but is not required to, follow the same procedure as an MCO under this rule; provided, however, that in no event shall a self-insuring employer require a injured worker to submit a written request for TENS supplies and/or equipment. The injured worker's MCO shall retain documentation of the contact with the injured worker substantiating the injured worker's need for supplies in accordance with the time frames set forth in rule 4123-6-14.1 of the Administrative Code. The TENS provider's bill must indicate the actual date of service, reflecting the date that services or supplies were provided. The bureau, MCO, QHP, or self-insuring employer may adjust bills upon audit if the audit discloses the provider's failure to comply with this rule.

(C) The TENS provider shall maintain the following records and make them available for audit upon request:

(1) Authorizations of TENS supplies or equipment received from the injured worker's MCO, and all other documentation relating to the injured worker's need for TENS supplies or equipment received by the provider prior to the delivery of the supplies or equipment, including any requests received from the injured worker, if applicable;

(2) Records of the provider's wholesale purchase of TENS supplies or equipment;

(3) Records of delivery of supplies to injured workers and of the delivery or return of TENS units; and

(4) The TENS provider's current, valid, license or certificate of registration from the state of Ohio board of pharmacy to sell or rent home medical equipment.

Upon request, the provider shall supply copies of the record information to the requester at no cost. Failure to provide the requested records may result in denial or adjustment of bills related to these records.

(D) The bureau shall not pay for the rental or sale of devices that are labeled by the food and drug administration (FDA) for over-the-counter use and are identified with the FDA product code "NUH.OTC.TENS."

(E) Payment will be approved for a neuromuscular electrical stimulator (NMES) unit for treatment of allowed conditions in a claim resulting from an allowed work related injury or occupational disease, as provided in the bureau's provider billing and reimbursement manual in effect on the billed date of service.

Last updated February 1, 2022 at 9:40 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 2/1/2027
Prior Effective Dates: 9/1/2016
Rule 4123-6-44 | Bureau fees for provider services rendered by in-state and out-of-state providers.
 

Bureau 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 the bureau to determine the need for appropriate adjustment.

Payment for provider services will be made in accordance with rule 4123-6-10 of the Administrative Code.

Last updated February 1, 2022 at 9:40 AM

Supplemental Information

Authorized By: : 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: : 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 2/1/2027
Prior Effective Dates: 2/1/2010
Rule 4123-6-45 | Audit of providers' patient and billing related records.
 

(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 4121.121 of the Revised Code, provider records may be reviewed before, during, or after the delivery of services. Reviews may be random, with no unreasonable infringement of provider rights, or may be for cause. Reviews may include the utilization of statistical sampling methodologies and projections based upon sample findings. Records reviews may be conducted at or away from the provider's place of business.

(2) Based on division (B)(15)(c) of section 4121.121 of the Revised Code, legible copies of providers' records may be requested. Providers shall furnish copies of the requested records within thirty calendar days of receipt of the request. The bureau shall establish a schedule for payment of reasonable costs for copying records, which shall be published in the health care provider billing and reimbursement manual.

(3) Original records shall not be removed from the provider's premises, except upon court order or subpoena issued by the bureau pursuant to section 4121.15 or 4123.08 of the Revised Code.

(B) Upon any finding of improper or unnecessary medical care, the administrator shall, if requested by the provider, appoint a subcommittee of the stakeholders' health care quality assurance advisory committee to review and advise the administrator as provided in paragraph (F) of rule 4123-6-22 of the Administrative Code. The administrator may sanction, suspend, or exclude a health care provider from participation in the workers' compensation system based on rule 4123-6-17 of the Administrative Code.

(C) The bureau or the MCO may deny payment for services or declare as overpaid previous payments to providers who fail to provide records or access to records to either the bureau or the MCO. The bureau may decertify a health care provider that fails to provide records requested pursuant to Chapters 2913., 4121., and 4123. of the Revised Code.

Last updated February 1, 2022 at 9:41 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 2/1/2027
Prior Effective Dates: 2/12/1997, 1/15/1999
Rule 4123-6-45.1 | Records to be retained by provider.
 

(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 payment for said goods or services, or five years from the date of referral to a certified or non-certified provider, or until any initiated audit or investigation is completed, whichever is longer. The provider shall create and maintain the records at the time the goods or services are delivered or within seven days from the date the service was rendered.

(B) The provider shall retain records documenting the following minimum information concerning the goods or services provided to injured workers:

(1) Date the service was provided;

(2) Description of service, treatment or product provided;

(3) Record of patient appointments, if appropriate;

(4) Dates where injured worker canceled or failed to appear for a scheduled examination, treatment, or procedure;

(5) Treatment plans;

(6) Subjective and objective complaints, if the provider is the practitioner or physician of record;

(7) Injured worker's progress, if the provider is the practitioner or physician of record;

(8) Wholesale purchase records, if goods, products, or prescriptions are delivered;

(9) Delivery records, if goods, products, or prescriptions are delivered by way of a third party;

(10) The identity and qualifications of any individual involved in the delivery of health care or billing for services to injured workers on behalf of the provider billing for the services.

(C) A provider's failure to create, maintain, and retain such records shall be sufficient cause for the bureau to deny payment for goods or services, to declare overpaid previous payments made to the provider, or to decertify the provider.

Last updated February 1, 2022 at 9:41 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 2/1/2027
Rule 4123-6-46 | Standardized or negotiated payment rates for services or supplies.
 

(A) The bureau or self-insuring employer may negotiate payment rates with health care providers for services and supplies provided in the treatment of workers' compensation claims.

(B) The bureau or self-insuring employer may enter into volume-based or optional-use contracts with medical providers for services including, but not limited to, the purchase or rental of durable medical equipment and supplies and catastrophic claim services.

(C) The bureau or self-insuring employer may inform injured workers of the availability of services, supplies, or equipment from particular health care providers with whom a contract for services or supplies, a negotiated payment rate for services or supplies, or a contract for cost-effective payment levels or rates has been entered into, so long as access to quality and convenient medical services or supplies for injured workers is maintained.

Last updated May 31, 2023 at 11:04 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.651, 4123.66
Five Year Review Date: 11/1/2026
Prior Effective Dates: 2/12/1997
Rule 4123-6-51 | Employer participation in the QHP system - bureau certification of QHPs.
 

(A) A health plan that satisfies the QHP certification requirements of this chapter shall be certified by the bureau as a QHP to manage medical treatment, direct care or provide services or supplies to or on behalf of an employee for an injury or occupational disease that is compensable under Chapter 4121., 4123., or 4131. of the Revised Code.

(B) An employer may establish a bureau certified QHP, that shall comply with the thirteen standards set forth in divisions (A)(1) to (A)(13) of section 4121.442 of the Revised Code, division (P) of section 4121.44 of the Revised Code, and rules 4123-6-53 and 4123-6-54 of the Administrative Code.

(C) The bureau is authorized to recertify QHPs at least every three years.

(D) The bureau, at least annually, shall develop and make available information that describes employer and employee rights under the QHP.

(E) The bureau shall continue to certify health plans and shall periodically, at least annually, update its list of certified QHPs.

Last updated May 31, 2023 at 11:04 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4121.442, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4121.442, 4123.66
Five Year Review Date: 8/1/2025
Prior Effective Dates: 9/5/1996, 2/1/2010
Rule 4123-6-52 | Employer participation in the QHP system - bureau recertification of QHPs.
 

(A) The bureau shall initiate the recertification process by sending certified QHPs a recertification application, which must be completed, signed and submitted to the bureau if the QHP wishes to be considered for recertification.

(B) Except as otherwise provided in paragraph (E) of this rule, if the bureau receives a completed and signed recertification application from a QHP, the QHP's certification shall remain in effect until the bureau issues a final order approving or denying the QHP's application for recertification.

(C) If the bureau does not receive a completed and signed recertification application from the QHP within sixty days from the date of the notice sent in accordance with paragraph (A) of this rule, the bureau shall send a second notice to the QHP stating that the QHP has thirty days from the date of the second notice to complete, sign and submit the recertification application to the bureau if the QHP wishes to be considered for recertification.

(D) If the bureau does not receive a completed and signed recertification application from the QHP within thirty days from the date of the notice sent in accordance with paragraph (C) of this rule, the QHP's certification shall lapse. Such lapse of certification is not an adjudication order and is not subject to appeal pursuant to rule 4123-6-17 of the Administrative Code.

(E) If the bureau receives a completed and signed recertification application from a QHP after the QHP's certification has lapsed pursuant to paragraph (D) of this rule, the QHP's certification shall remain lapsed until the bureau issues a final order approving or denying the QHP's application for recertification.

Last updated May 31, 2023 at 11:04 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.44, 4121.441, 4121.442, 4121.31, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4121.442
Five Year Review Date: 8/1/2025
Rule 4123-6-53 | Employer participation in the QHP system - QHP quality assurance program required.
 

(A) Each QHP shall have a quality assurance program that monitors the operation and measures the effectiveness of peer review, utilization review, and dispute resolution within the QHP. Data collected from the quality assurance program shall be used to assist an employer in determining the quality, efficiency and effectiveness of the employer's QHP and the QHP system in accordance with division (A) of section 4121.442 of the Revised Code.

(B) Each quality assurance program shall include a mechanism for monitoring and the methodology for measuring and improving the QHP's compliance with each of the following eleven elements:

(1) Peer review and evaluation of clinical performance;

(2) Credentialing 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) Evaluation of provider satisfaction with the plan;

(9) Evaluation of employer satisfaction with the plan;

(10) Periodic evaluation of medical records and office procedures; and

(11) Practice patterns compared to accepted medical criteria.

(C) The quality assurance program shall include a quality assurance committee or other mechanism adequate to evaluate the outcomes of each of the eleven elements listed in paragraph (B) of this rule.

Last updated May 31, 2023 at 11:04 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4121.442, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4121.442
Five Year Review Date: 8/1/2025
Prior Effective Dates: 9/5/1996
Rule 4123-6-54 | Employer participation in the QHP system - QHP certification application.
 

(A) Upon request by an employer or health plan seeking certification, the bureau shall mail the employer or health plan seeking certification a QHP application for certification.

(B) The QHP application for certification shall 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, fraud, or deceit;

(2) Proof that a self-insured employer has been granted status as a self-insured employer in accordance with section 4123.35 of the Revised Code;

(3) A description of the geographic or regional area of the state of Ohio to be serviced by the QHP, taking into account the unique circumstances of the individual employer, such as multiple locations, and/or the need for a statewide network;

(4) A description of the role of each vendor that will be a component of the QHP including, but not limited to, the following: if an employer uses or anticipates using company-based providers, a description of the role of company-based providers as distinguished from QHP network providers; if an employer uses or anticipates using a third party administrator, a description of the role of the third party administrator;

(5) If an employer contemplates contracting with a vendor that has been certified by the bureau under Chapter 4123-6 of the Administrative Code to provide services under the employer's QHP, proof that certification has been granted by the bureau and that such certification is current;

(6) A description of the structure of the medical management component and the health care provider network to be offered by the QHP;

(7) A description of the QHP's plan and methodology for providing, at least annually, QHP network provider information, by provider type, and updated QHP network provider directories to employees;

(8) A description of the QHP's quality assurance program, including but not limited to, the proposed structure and operation and a description of the mechanism for monitoring and the methodology for measuring and improving the QHP's compliance with the elements listed in paragraph (B) of rule 4123-6-53 of the Administrative Code;

(9) A description of the QHP's employee education program. The description shall include but shall not be limited to: a description of the process to be used to educate employees regarding their rights and responsibilities in the QHP system; a description of the process to be used to explain the time, place and manner of services to be delivered under the QHP; and a description of the process to be used to explain options available to injured workers, including the process for changing providers within the QHP and referral and transfer to the HPP; and

(10) A description of the plan satisfactory to the bureau to be implemented by the QHP in the event a final order to revoke certification, or to refuse to recertify a QHP is issued by the administrator, pursuant to rule 4123-6-55 of the Administrative Code, that includes, but is not limited to, a plan that describes continuation and continuity of care of injured workers and a plan that describes payment of providers for medical services rendered prior to revocation of certification or refusal to certify. The injured worker may continue receiving medical services from the same provider or may choose a provider in a new approved plan for delivery of medical services, both of whom shall accept medical management of the medical services through the employer's new approved plan.

(D) The bureau shall review the application for certification submitted by the health plan seeking certification. The bureau reserves the right to cross-check data with other governmental agencies or licensing or accrediting bodies.

(E) The bureau shall hold as confidential and proprietary the vendor's descriptions of process, methodology, policies, procedures and systems as required for the application for certification, to the extent such qualify as a "trade secret" under division (D) of section 1333.61 of the Revised Code.

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Five Year Review Date: 8/1/2025
Rule 4123-6-55 | Employer participation in the QHP system - bureau's authority to decertify, to refuse to certify or recertify a QHP.
 

(A) The bureau is authorized to decertify, to refuse to certify or recertify a QHP from participation in the QHP system.

(B) Should the bureau determine that sufficient evidence exists that an employer or QHP has failed to comply with applicable workers' compensation statutes or rules governing QHPs, the bureau will take one of two courses of action:

(1) The bureau will serve written notice to the employer, employee representative and QHP of the facts and issues relating to the bureau's determination that the employer or QHP has failed to comply with applicable workers' compensation statutes or rules governing QHPs. Such notice will set forth a period of time for the employer or QHP to resolve or correct the problem. Failure of the employer or QHP to resolve or correct the problem within the time period will result in the bureau serving notice to the employer and QHP in writing of administrative action that might result in a bureau determination to revoke certification, refusal to certify or recertify, and the employer's and QHP's right to a hearing within thirty days of the notice, if requested by the employer or QHP, pursuant to rule 4123-6-17 of the Administrative Code.

(2) Serve written notice to the employer, employee representative and QHP of administrative action that might result in a bureau determination to revoke certification, refusal to certify or recertify, and the employer's and QHP's right to a hearing within thirty days of the notice, if requested by the employer or QHP, pursuant to rule 4123-6-17 of the Administrative Code.

(3) For the purpose of this rule, "employee representative" does not include the employee's attorney.

(4) The bureau will serve all notices pursuant to this rule in accordance with section 119.05 of the Revised Code.

(C) Upon a final order of the administrator to decertify, refuse to recertify, or revoke or suspend the certification of a QHP, employees and employers cannot receive services from such QHP pursuant to the QHP system.

Last updated April 15, 2024 at 8:32 AM

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4121.442, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4121.442
Five Year Review Date: 8/1/2025
Rule 4123-6-58 | Provider access to the QHP system - provider participation in QHP system and other related health care program not linked.
 

A QHP or vendor that provides medical management and cost containment 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.

Last updated May 31, 2023 at 11:30 AM

Supplemental Information

Authorized By: 4121.12, 4121.30, 4121.31, 4123.05
Amplifies: 4121.121, 4121.44, 4121.441, 4121.442, 4123.66
Five Year Review Date: 8/1/2025
Prior Effective Dates: 9/5/1996
Rule 4123-6-59 | Provider access to the QHP system - QHP provider selection.
 

(A) An employer that develops a QHP, a vendor within the QHP system, or a QHP shall develop and implement 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 QHP panel provider or by a vendor as a panel provider to participate in the QHP system. A provider identified by a QHP for inclusion in its panel of providers that is not a bureau certified provider may be assisted by the QHP in applying for bureau provider credentialing and certification.

(D) The bureau, an employer, a QHP or a vendor shall not discriminate against any category of health care provider when establishing categories of providers for participation in the QHP system. However, an employer, a QHP or a vendor is not required to accept or retain any individual provider in the QHP system.

(E) The bureau, an employer, a QHP and a vendor shall comply with state and federal laws prohibiting discrimination based on race, color, religion, sex, age, disability, military status as defined in section 4112.01 of the Revised Code, national origin, ancestry, or sexual orientation.

(F) A QHP shall include in its panel a substantial number of the medical, professional, and pharmacy providers currently being utilized by employees. A QHP may limit the number of providers on its provider panel, but shall do so based upon objective data that demonstrates that the fundamental needs of the employer and employees are met based on reasonable standards such as historical claims data or other geographic information approved by the bureau. In addition, a QHP shall include in its application for QHP certification information including reasonable patient access, the potential number of employees the QHP is applying to service, and other performance criteria, without discrimination by provider type. A QHP seeking QHP certification may select out-of-state providers as members of the QHP panel.

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4121.442, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4121.442
Five Year Review Date: 8/1/2025
Rule 4123-6-65 | Payment in the QHP system - employer payment to vendor that provides medical management and cost containment services and/or QHPs.
 

The bureau shall not interfere with nor impose restrictions upon an arrangement for payment negotiated between an employer and a vendor that provides medical management and cost containment services and/or a QHP under the QHP system, except that no financial arrangement between an employer and a vendor that provides medical management and cost containment services and/or a QHP shall incentivize a reduction in the quality of medical care received by an injured worker.

Last updated May 31, 2023 at 11:30 AM

Supplemental Information

Authorized By:
Amplifies:
Five Year Review Date:
Rule 4123-6-69 | QHP dispute resolution process.
 

(A) This rule shall provide time frames and procedures for review of requests for the delivery of medical services and for the resolution of disputes that may arise between an employee 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 care providers.

(B) Initial review and decision upon requests for the delivery of medical services that include, but are not limited to, medical treatment, major diagnostic testing, hospitalization, surgery and physical therapy, shall be completed by the QHP. The employee, employer and provider shall be notified verbally of the outcome of the initial review within forty-eight hours of the request. Within seven working days of the verbal notification, the verbal notification shall be committed to writing and mailed to the employee, employer and provider.

(C) A QHP shall have a dispute resolution process beyond initial review that includes one independent level of professional review.

(D) A QHP dispute resolution process shall be completed and the QHP shall notify the parties to the dispute and their representatives in writing within twenty-one days of the initial written notice of a dispute, unless an extension of time is otherwise agreed to by the parties. If the QHP schedules the injured worker for an independent medical examination for the independent level of professional review, the twenty-one day time frame shall be tolled, and in such cases the QHP shall complete the dispute resolution process within seven days after receipt of the independent medical examination report.

(E) The dispute resolution process shall begin upon written notice of the dispute by the party maintaining the dispute to the parties of the dispute.

(1) If an individual health care provider eligible to be physician of record would be providing the services requested in the dispute, the independent level of professional review shall consist of a peer review conducted by an individual or individuals licensed pursuant to the same section of the Ohio Revised Code as the health care provider who would be providing the services requested.

(2) Notwithstanding paragraph (E)(1) of this rule, if the QHP has already obtained one or more peer reviews during previous disputes involving the same or similar treatment, the QHP may obtain a different perspective review from a licensed physician who falls outside the peer review criteria set forth in this paragraph.

(3) ) If an individual health care provider not eligible to be physician of record would be providing the services requested in the dispute, the independent level of professional review shall consist of a provider review conducted by an individual or individuals eligible to be physician of record whose scope of practice includes the services requested.

(4) If the QHP receives a dispute where the requested treatment appears to be the same as or similar to a previous treatment request for which the QHP conducted a professional review, and the previous treatment request was ultimately denied based on the professional review, the QHP may use the previous professional review to satisfy the independent level of professional review requirement of this paragraph.

(F) A dispute unresolved by a QHP dispute resolution process may be appealed to the industrial commission pursuant to section 4123.511 of the Revised Code. Parties to a dispute shall exhaust the dispute resolution procedures of this rule prior to filing an appeal under section 4123.511 of the Revised Code.

(G) Notwithstanding the requirements set forth in paragraph (F) of this rule, a dispute unresolved by a QHP providing medical management and cost containment services for a state fund employer shall be referred by the QHP to the bureau within seven working days of the final decision rendered within the QHP dispute resolution process. Within fourteen days of receipt of an unresolved medical dispute, the bureau shall conduct an independent review of the unresolved medical dispute received from the QHP and enter a final bureau order pursuant to section 4123.511 of the Revised Code. This order shall be mailed to all parties and may be appealed to the industrial commission pursuant to section 4123.511 of the Revised Code. Parties to a dispute shall exhaust the dispute resolution procedures of this rule prior to filing an appeal under section 4123.511 of the Revised Code.

Supplemental Information

Authorized By: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4121.442, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4121.442
Five Year Review Date: 8/1/2025
Prior Effective Dates: 9/5/1996
Rule 4123-6-70 | Evaluation of the QHP system by the bureau; reporting requirements by employers and QHPs.
 

(A) To enhance the quality of the QHP system, and pursuant to division (A)(9) of section 4121.442 of the Revised Code, the administrator shall require employers and QHPs that participate in the workers' compensation QHP system to report data to be used by the administrator to measure and perform comparison analyses of costs, quality, appropriateness of medical care, and effectiveness of medical care delivered by all components of the workers compensation system.

(B) The bureau shall evaluate the effectiveness of the QHP system based on standardized data and reporting requirements developed by the bureau.

(C) The bureau shall receive, define and publish data elements and data collection techniques that meet the thirteen standards set forth in divisions (A)(1) to (A)(13) of section 4121.442 of the Revised Code and are necessary to evaluate the effectiveness of the QHP system. Performance indicators used by the bureau to evaluate the effectiveness of the QHP system may include, but shall not be limited to, the following: customer satisfaction; system cost drivers; improvements in quality, and cost reductions.

Last updated May 31, 2023 at 11:30 AM

Supplemental Information

Authorized By: 4121.12, 4121.30, 4121.31, 4123.05
Amplifies: 4121.121, 4121.44, 4121.441, 4121.442, 4123.66
Five Year Review Date: 8/1/2025
Prior Effective Dates: 9/5/1996
Rule 4123-6-72 | Confidentiality.
 

Subject to the requirements and protections contained in Ohio law pertaining to release of confidential and/or privileged information, in the course of medical management in the QHP system, confidential information may be exchanged among the bureau, the QHPs, an employer and its representative, an employee 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.

Last updated May 31, 2023 at 11:30 AM

Supplemental Information

Authorized By: 4121.12, 4121.12, 4121.30, 4121.31, 4121.44, 4121.441, 4121.442, 4123.05
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4121.442
Five Year Review Date: 8/1/2025
Prior Effective Dates: 9/5/1996