reglab/statecodes huggingface dataset:
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-03.10 - Conflict of interest

Current through all regulations passed and filed through July 1, 2024
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 .
Effective:
				2/1/2010
R.C. 119.032 review dates:
				11/17/2009 and
				02/01/2015
Promulgated
				Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30,
				4121.31, 4123.05
Rule Amplifies: 4121.121, 4121.44, 4121.441,
				4123.66
Prior Effective Dates:
				1/1/01
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-04.3 - MCO scope of services - MCO medical management and claims management assistance

Current through all regulations passed and filed through July 1, 2024
(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.
Replaces: 4123-6- 04.3, 4123-6- 04.4, and 4123-6- 06.1
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-04.5 - MCO scope of services - bureau claims management

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-04.6 - Return to work assessment

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-05.2 - Employer access to the HPP - employer enrollment and selection of MCO

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-05.3 - Employer access to the HPP - certain solicitation practices by MCOs prohibited

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-05.4 - Employer access to the HPP - payment for referrals prohibited

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-06.2 - Injured worker access to the HPP - injured worker choice of provider

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-07 - Services and supplies never covered

Current through all regulations passed and filed through July 1, 2024
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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-08 - Bureau fee schedule

Current through all regulations passed and filed through July 1, 2024
(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.
Click to view
				Appendix
Click to view
				Appendix
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-14 - MCO bill submission to bureau

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-14.1 - Records to be retained by MCO

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-15 - Confidentiality of records

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-16 - Alternative dispute resolution for HPP medical issues

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-16.1 - HPP medical treatment guidelines

Current through all regulations passed and filed through July 1, 2024
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.
Replaces: Replacing 4123-6- 16.1
Effective:
				2/1/2010
R.C. 119.032 review dates:
				11/01/2014
Promulgated
				Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30,
				4121.31, 4123.05
Rule Amplifies: 4121.121, 4121.44, 4121.441,
				4123.66
Prior Effective Dates: 4/29/98, 9/12/04
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-16.2 - Medical treatment reimbursement requests

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-16.3 - Reimbursement of retroactive medical treatment reimbursement requests

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-17 - Bureau refusal to certify or recertify, action to decertify a provider, MCO, or QHP - standards and procedures for adjudication hearings

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-18 - Data gathering and reporting

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-19 - Remain at work services

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-20 - Obligation to submit medical documentation and reports

Current through all regulations passed and filed through July 1, 2024
(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, and documentation 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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-20.1 - Access to medical documentation

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-21 - Payment for outpatient medication

Current through all regulations passed and filed through July 1, 2024
(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 noncertified 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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-21.1 - Payment for outpatient medication by self-insuring employer

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-21.2 - Pharmacy and therapeutics committee

Current through all regulations passed and filed through July 1, 2024
The bureau of workers' compensation pharmacy and therapeutics
				(P&T) committee is hereby created to advise the administrator
				 with regard
				to issues involving medication therapy for injured workers. A list of physician
				and pharmacist providers, each holding a professional license in good standing,
				who have expressed an interest in serving on the P&T
				committee and who would add credibility and diversity to the mission and goals
				of the committee shall be developed and maintained by the
				bureau. Providers may also be nominated for inclusion
				on the list by provider associations and organizations 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 pharmacy board.
(A) The P&T committee shall consist of
			 the 
								bureau's pharmacy program director, the bureau's chief medical officer, the industrial
			 commission's medical advisor, and not more than thirteen nor less than
			 five voting members who shall be licensed physicians and licensed pharmacists
			 representing the diverse group of providers that provide care to the injured
			 workers of Ohio as administered 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 P & T committee.
(B) P&T committee members must meet the
			 following requirements:
(1) Each provider must
			 be familiar with issues relating to the prescribing or dispensing of
			 medications in the Ohio workers' compensation system.
(2) Physicians must be a doctor of medicine
			 (MD) or doctor of osteopathic medicine (DO).
(3) Providers must 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) Providers must have experience with and
			 an understanding of the concepts of evidence based medicine as well as
			 contemporary best practices in appropriate prescribing, dispensing, and
			 monitoring of outpatient medications.
(5) Providers must 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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-21.3 - Outpatient medication formulary

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-21.4 - Coordinated services program

Current through all regulations passed and filed through July 1, 2024
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 sedativehypnotics per
			 three month time frame.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-21.5 - Standard dose tapering schedules

Current through all regulations passed and filed through July 1, 2024
(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.