reglab/statecodes huggingface dataset:
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-3 - Claims Procedure › Section 4123-3-23 - Limitations on the filing of fee bills

Current through all regulations passed and filed through July 1, 2024
(A) Except as otherwise provided in this
			 rule, fee bills for medical or vocational rehabilitation services rendered in a
			 claim shall be submitted to the bureau or commission for payment within one
			 year of the date on which the service was rendered or one year after the date
			 the services became payable under division (I) of section
			 4123.511
			 of the Revised Code, whichever is later, or shall be forever barred.
(B) A self-insuring employer may, but is not
			 required to, negotiate with a provider to accept fee bills from the provider
			 for a time period other than as set forth in paragraph (A) of this
			 rule.
(C) Paragraph (A) of this
			 rule shall not apply to the following:
(1)
			 Requests made by the centers for medicare and medicaid services in the United
			 States department of health and human services for reimbursement of conditional
			 payments made pursuant to section 1395y(b)(2) of title 42, United States Code
			 (commonly known as the "Medicare Secondary Payer Act")
			 ;
(2) Requests made
			 by the Ohio department of medicaid, or by a medical assistance provider to whom
			 the department has assigned its right of recovery for a claim for which it has
			 notified the provider that it intends to recoup its prior payment for a claim,
			 for reimbursement under sections
			 5160.35
			 to
			 5160.43
			 of the Revised Code for the cost of medical assistance paid on behalf of a
			 medicaid recipient;
(3)
									Requests made by the department of veterans affairs
			 (VA) pursuant to section 1729 of title 38, United States Code for reimbursement
			 of medical treatment provided to an injured worker in or through any VA
			 provider or facility;
(4) Fee bills submitted
			 outside the timeframe set forth in paragraph (A) of this rule due to MCO or
			 bureau error; however, division (A) of section
			 4123.52
			 of the Revised Code shall still apply;
(5) Fee bills submitted
			 outside the timeframe set forth in paragraph (A) of this rule because the fee
			 bills were initially submitted to a patient, different third-party payer, or
			 state or federal program other than medicare,
									 medicaid, or the
			 VA that reimburses for medical or vocational rehabilitation services and
			 that patient, payer, or program has determined that it is not responsible for
			 the cost of the services; however, division (A) of section
			 4123.52
			 of the Revised Code shall still apply.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-3 - Claims Procedure › Section 4123-3-24 - Fee controversies

Current through all regulations passed and filed through July 1, 2024
When a controversy exists between a party and the party's
				representative concerning fees for services rendered in industrial claims,
				either the party or the representative may make a written request to the
				commission to resolve the dispute. Such request must be completed and filed in
				accordance with the rules of the industrial commission, the matter being within
				the exclusive jurisdiction of the industrial commission. Any such request, if
				filed with the bureau, shall be referred, forthwith, to the industrial
				commission for further consideration.
R.C. 119.032 review dates:
				01/07/2014 and
				01/01/2019
Promulgated
				Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30,
				4121.31
Rule Amplifies: 4121.12, 4121.121, 4123.06
Prior
				Effective Dates: 1/1/64, 1/16/78,
				2/10/09
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-3 - Claims Procedure › Section 4123-3-25 - Application for change of occupation allowance

Current through all regulations passed and filed through July 1, 2024
(A) Eligibility for a change of occupation
			 allowance.
(1) Where it is found that a change of
			 occupation is medically advisable for an employee suffering from silicosis,
			 coal miners' pneumoconiosis, or asbestosis contracted in the course of
			 employment, but the employee is not totally disabled therefrom, and any other
			 diseases which may be specified by law for which the statutory allowance for
			 change of occupation may be granted, or
(2) Where it is found that a change of
			 occupation is medically advisable for a fire fighter or police officer
			 suffering from a cardiovascular and pulmonary disease contracted in the course
			 of employment, but the employee is not totally disabled therefrom,
(3) Pursuant to the provisions of section
			 4123.57 of the Revised Code,
			 such employee shall file a motion in accordance with paragraph (A) of rule
			 4123-3-16 of the
			 Administrative Code requesting the approval of the statutory allowance for such
			 change of occupation, in order to decrease substantially further injurious
			 exposure.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-3 - Claims Procedure › Section 4123-3-29 - Informing the claimant of the right to representation and status of the claim

Current through all regulations passed and filed through July 1, 2024
(A) Whether a claimant is or is not
			 represented in an industrial claim is a matter of the claimant's free choice.
			 No employee of the bureau or of a self-insuring employer shall directly or
			 indirectly convey any information in derogation of this right.
(B) Upon receipt of a claim the bureau shall
			 notify the claimant and the employer of the number assigned to the claim. Also,
			 the claimant shall be informed of his or her right to representation or to
			 elect no representation in the processing of the claim. It shall be the
			 responsibility of the bureau to aid and assist a claimant in the filing of a
			 claim as provided in division (A) of section 
								
									4123.511
								 of the Revised
			 Code.
(C)
								
			 Upon request, the bureau shall inform the claimant of the status of the claim
			 and of any action necessary to maintain the claim.
Effective:
				4/1/2014
R.C. 119.032 review dates:
				01/07/2014 and
				04/01/2019
Promulgated
				Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30,
				4121.31
Rule Amplifies: 4121.12, 4121.121
Prior Effective
				Dates: 1/16/78, 2/10/09
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-3 - Claims Procedure › Section 4123-3-31 - Disabled workers' relief fund: claimant's payments

Current through all regulations passed and filed through July 1, 2024
(A) On and after
			 August 22, 1986, all persons, without regard to date of injury, who are
			 receiving compensation for permanent and total disability which, when combined
			 with disability benefits received pursuant to the Social Security Act, is less
			 than three hundred forty-two dollars per month adjusted annually as provided in
			 division (B) of section
			 4123.62 of the Revised Code,
			 shall be eligible to participate in the disabled workers' relief fund. For
			 purposes of this rule, this amount shall be referred to as the "DWRF qualifying
			 figure."
(B) Each person who has
			 satisfied the requirements of paragraph (A) of this rule shall receive from the
			 disabled workers' relief fund a monthly amount equal to either the difference
			 between the DWRF qualifying figure and such amount as the person is receiving
			 per month as disability benefits from the social security administration or the
			 difference between the DWRF qualifying figure and such amount as the person is
			 receiving under the workers' compensation laws for permanent total disability,
			 whichever calculation results in the lower DWRF payment.
(C)
			 For purposes of this rule, in the case of individuals who have received a
			 commutation of permanent total disability benefits pursuant to the provisions
			 of section 4123.64 of the Revised Code,
			 payments from the disabled workers' relief fund shall be calculated as if such
			 commutation had not been made.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-3 - Claims Procedure › Section 4123-3-34 - Settlement of state fund claims

Current through all regulations passed and filed through July 1, 2024
(A) The procedures of this rule shall apply
			 to the settlement of state fund injury and occupational disease
			 claims.
(B) The employer or the
			 claimant shall file an application for approval of settlement agreement on the
			 appropriate form with the administrator of workers' compensation. Each
			 application shall include the signature of the claimant and the employer, or
			 their authorized legal representative, except as follows:
(1) A claimant may file an application
			 without an employer's signature in the following situations:
(a) The employer is no longer doing business
			 in Ohio;
(b) The claim no longer is
			 in the employer's industrial accident or occupational disease experience as
			 provided in division (B) of section
			 4123.34
			 of the Revised Code and the claimant no longer is employed with that employer;
			 or,
(c) The employer has failed to
			 comply with section
			 4123.35
			 of the Revised Code.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-3 - Claims Procedure › Section 4123-3-35 - Employer disability relief

Current through all regulations passed and filed through July 1, 2024
(A)
			 For the purposes of 
								disability relief under section
			 4123.343 of the Revised Code,
			 
								an "employee with a disability" means an employee
			 who is defined as having one or more of the conditions listed in division (A)
			 of section 4123.343 of the Revised Code.
(1) With respect to the
			  condition defined in division
			 (A)(4) of section 4123.343 of the Revised Code,
			 degenerative disc disease, spondylosis, spondylolysis, and spondylolisthesis do
			 not constitute evidence of arthritis for purposes of satisfying the
			 statute.
(2) With respect to the
			  condition defined in division
			 (A)(14) of section 4123.343 of the Revised Code,
			 the employee must have 
									inpatient  treatment and admission for the
			 psycho-neurotic disability in a recognized medical or mental institution.
			 Outpatient treatment does not satisfy the statutory
			 definition.
(3) With respect to the
			  condition defined in division
			 (A)(25) of section 4123.343 of the Revised Code, an
			 employer is not eligible for 
									disability relief in the
			 same claim in which the employee participated in a rehabilitation program. The
			 employee must suffer a subsequent compensable injury or occupational disease
			 claim, and any  rights
			 to disability relief would be in the subsequent
			 claim.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-3 - Claims Procedure › Section 4123-3-36 - Immediate allowance and payment of medical bills in claims

Current through all regulations passed and filed through July 1, 2024
(A) In accordance
			 with division (A) of section
			 4123.511 of the Revised Code the
			 administrator has established a program to immediately allow specific medical
			 conditions which have a historical record of being allowed whenever included in
			 a claim and having low medical costs.
The medical conditions that the
				administrator has determined to be included in the program are indicated in the
				appendix to this rule.
(B) Upon the
			 initial filing of a claim, the administrator shall investigate the claim and
			 issue an order on the claim as required by section
			 4123.511 of the Revised Code.
			 The administrator shall consider all of the necessary evidence and relevant
			 laws and rules for the determination of the allowance of a claim. For any
			 medical condition identified in appendix A to this rule, however, the
			 administrator may grant immediate allowance of the medical condition and may
			 make immediate payment of the medical bills relating to that condition,
			 regardless of the receipt of the medical reports for that medical condition or
			 the employer's certification of the claim.
(C) The employer retains the right to contest
			 the immediate allowance and payment of a medical condition in a claim under
			 this rule. If the employer appeals the allowance and payment and the claim is
			 disallowed, the payment for the medical treatment provided prior to the date of
			 the disallowance of that claim shall be charged to and paid from the surplus
			 fund created under section
			 4123.34 of the Revised Code. The
			 administrator shall not seek reimbursement of the payment from the
			 
								claimant or the provider.
Click to view
				Appendix
Click to view
				Appendix
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-3 - Claims Procedure › Section 4123-3-37 - Lump sum advancements

Current through all regulations passed and filed through July 1, 2024
(A) The administrator of the bureau of
			 workers' compensation, under special circumstances, may commute an award of
			 compensation to a lump sum payment when the administrator determines
			  the advancement is advisable for the
			 purpose of providing the claimant or the surviving spouse financial relief or
			 for furthering the claimant's rehabilitation.
(1) The bureau may grant a lump sum
			 advancement to a claimant only from an award of compensation made pursuant to
			 section 4123.58 of the Revised Code or
			 from division (A) or (B) of section
			 4123.57 of the Revised
			 Code.
(2) The bureau may grant a
			 lump sum advancement to a surviving spouse only from an award of death benefits
			 made pursuant to section
			 4123.59 of the Revised Code.
			 However, the advancement 
									cannot exceed the amount of death benefits
			 payable to the surviving spouse over a two-year period.
(3) The bureau 
									will not grant
			 a lump sum advancement to a surviving dependent from an award of compensation
			 made pursuant to division (B) of section
			 4123.57 of the Revised
			 Code.
(4) The bureau
			 
									will
			 not grant a lump sum advancement in a claim where the allowance of the award of
			 compensation made pursuant to section
			 4123.58 of the Revised Code or
			 from division (A) or (B) of section
			 4123.57 of the Revised Code is
			 on appeal under section
			 4123.511 of the Revised Code or
			 an appeal to court.
(5) The
			 industrial commission has exclusive jurisdiction over an application for a lump
			 sum advancement for the payment of attorney fees incurred in securing an award.
			 The bureau 
									will refer such applications to the industrial
			 commission to adjudicate.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-3 - Claims Procedure › Section 4123-3-38 - Surplus fund charge of qualified motor vehicle accident claims

Current through all regulations passed and filed through July 1, 2024
(A) Pursuant to
			 section 4123.932 of the Revised Code and
			 when an employer satisfies all of the requirements of this rule, the bureau
			 shall charge to the surplus fund created under division (B) of section
			 4123.34 of the Revised Code any
			 compensation and benefits related to a compensable workers' compensation claim
			 based on a motor vehicle accident involving a third party. This rule applies
			 only to claims arising on or after July 1, 2017.
(B) Eligibility requirements.
(1) This rule does not apply to self-insuring
			 employers, state agencies, or a state institution of higher education,
			 including its hospitals.
(2) This
			 rule applies to private state fund employers and public employer taxing
			 district employers that pay premiums into the state insurance fund.
(a) The employer must have had active
			 workers' compensation coverage on the date of injury of the claim.
(b) The employer must be current with respect
			 to all payments due the bureau, as defined in paragraph (A)(1)(b) of rule
			 4123-17-14
			 of the Administrative Code.
(c) The
			 employer must be current on the payment schedule of any part-pay agreement into
			 which it has entered for payment of premiums or assessment obligations.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-5 - Miscellaneous Provisions › Section 4123-5-01 - Assignment of duties to the bureau's operational units

Current through all regulations passed and filed through July 1, 2024
The administrator of workers'
				compensation may reorganize the work of the bureau
				of workers' compensation to the extent necessary
				to achieve the most efficient performance of its functions. The duties of the
				operational units of the bureau include, but are not limited to the
				following:
(A) A division responsible
			 for the fiscal and planning function 
								to assist the administrator in maintaining the
			 solvency of the insurance fund, establishing policies and procedures for fiscal
			 management, receiving and disbursing funds from the state insurance fund, and
			 preparing the bureau's budget.
(B)
			 A division responsible for the medical services function
			 
								to
			 assist the administrator in establishing and maintaining a quality pool of
			 medical and vocational service providers, developing and maintaining quality
			 medical, vocational rehabilitation, and pharmaceutical benefits plans,
			 overseeing managed care services, and ensuring the proper and timely payment of
			 medical bills.
(C) A department
			 responsible for the special investigations function 
								to conduct
			 investigations of alleged workers' compensation fraud and alleged violations of
			 specific safety requirements pursuant to workers' compensation
			 claims.
(D) A division or divisions
			 responsible for the customer service function 
								to assist the
			 administrator in:
(1) Identifying employers
			 subject to the Ohio Workers' Compensation Act;
(2) Conducting periodic reviews of the manual
			 classifications and payroll reports of state fund employers to ensure that
			 employer premium payments have been properly computed and paid;
(3)
			 Developing and making available alternative premium plans to state fund
			 employers;
(4) Managing the claims
			 of 
									claimants in accordance with applicable statutes,
			 rules and policies;
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-5 - Miscellaneous Provisions › Section 4123-5-11 - Employer's reports must be signed by officer or person in employ of employer

Current through all regulations passed and filed through July 1, 2024
The bureau of workers' compensation will not accept an
				employer's report on application for payment of compensation and/or benefits,
				payroll reports, settlement sheets, and other instruments, which employers are
				required to submit to the bureau  unless the document is signed by an officer in the
				organization of the employer, or a person in the employ of the employer, who is
				duly authorized to sign such instruments. The person signing such instruments
				for the employer shall indicate in what capacity the person is employed
				(title). No instruments purporting to authorize any service organization or any
				other person to sign such instruments for an employer shall be recognized as
				granting such authority.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-5 - Miscellaneous Provisions › Section 4123-5-13 - Expenses related to the work-related death of an employee

Current through all regulations passed and filed through July 1, 2024
(A) The date of
			 death shall govern the amount of funeral benefits to be paid in a death claim
			 for the funeral expenses of an employee who has died as a result of an
			 allowed work-related industrial injury or
			 occupational disease. In such cases no disbursements shall be made in excess of
			 the amount allowed by law for funeral expenses.
(B) In cases where an attempt was made by the
			 ambulance service, by a physician or at a hospital emergency room to revive the
			 employee and such attempt was in the nature of treatment (e.g. use of oxygen,
			 artificial respiration, injection, medication, electro-shock, etc.), payment
			 for such services and for the use of equipment shall be made in addition to the
			 payment for funeral expenses. The bureau may make payment for exceptional
			 transportation costs in addition to the payment of funeral expenses. (e.g.
			 returning the body of the deceased employee when the death occurred outside the
			 area where the deceased lived.)
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-5 - Miscellaneous Provisions › Section 4123-5-18 - Medical proof required for payment of compensation

Current through all regulations passed and filed through July 1, 2024
(A) Except as provided in paragraph (E) of
			 this rule and paragraph (B)(1)(b) of rule
			 4123-3-09
			 of the Administrative Code, no payment of compensation shall be approved by the
			 bureau of workers' compensation in a claim unless
			 supported by a report of a physician duly licensed to render the
			 treatment.
(B) When evaluating the
			 sufficiency of medical proof, the following criteria shall be considered:
(1) The nature and type of injury or
			 occupational disease;
(2) The
			 consistency of the diagnosis with the description of events resulting in the
			 injury or occupational disease, as shown by proof of record;
(3) Whether the disability is based solely on
			 the condition or conditions for which the claim is recognized;
(4) Whether the disability is based on
			 objective symptoms of disability as a direct result of the injury or
			 occupational disease in the respective claim; "objective symptoms" means those
			 signs and indications which are discovered from an examination of the claimant,
			 as distinguished from subjective symptoms which are reported by the
			 claimant;
(5) Whether a reason or
			 reasons for the medical opinion are stated.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-5 - Miscellaneous Provisions › Section 4123-5-21 - Abatement of claims

Current through all regulations passed and filed through July 1, 2024
(A) When a claimant dies, action on any
			 application filed by the claimant, and pending before the bureau
			 of workers' compensation or the industrial
			 commission at the time of his death, is abated by claimant's death.
(B) Abatement of action, as described in
			 paragraph (A) of this rule, does not apply to payment for medical and hospital
			 treatment, for medicine, nursing, and other health care services rendered as a
			 result of the injury or occupational disease for which the claim was allowed
			 during the deceased claimant's lifetime, provided that the respective bills
			 were filed within the time as required by law and by the rules of the
			 industrial commission and the bureau.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-01.1 - Applicability of medical rules

Current through all regulations passed and filed through July 1, 2024
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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-01.2 - Provisional treatment reimbursement approval - pilot program

Current through all regulations passed and filed through July 1, 2024
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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-02 - Provider access to the HPP - generally

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-02.2 - Provider access to the HPP - provider certification criteria

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-02.21 - Provider access to the HPP - non-certified provider enrollment

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-02.4 - Provider access to the HPP - provider recertification

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-02.5 - Provider access to the HPP - provider not certified

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-02.51 - Provider access to the HPP - Denial of provider, entity or MCO enrollment or certification based on criminal conviction or civil action

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-02.6 - Provider access to the HPP - selection by an MCO

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-02.8 - Provider requirement to notify of injury

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-02.9 - Provider access to the HPP - provider marketing

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-03.2 - MCO participation in the HPP - MCO application for certification or recertification

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-03.4 - MCO participation in the HPP - MCO certification

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-03.7 - MCO participation in the HPP - bureau's authority to decertify, to refuse to certify or recertify an MCO

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-03.9 - MCO participation in the HPP - MCO disclosure of relationship

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