Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-02.7 - Provider access to the HPP - provider decertification procedures

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