reglab/statecodes huggingface dataset:
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-21.6 - `First fill of outpatient medications

Current through all regulations passed and filed through July 1, 2024
(A) In accordance with division (B) of
			 section 4123.66 of the Revised Code, the
			 administrator has established a program to make immediate payment, under the
			 circumstances set forth in this rule, for the first fill of prescription drugs
			 for medical conditions identified in an application for compensation or
			 benefits under section
			 4123.84 or
			 4123.85 of the Revised Code that
			 occurs prior to the date the administrator issues an initial determination
			 order under division (B) of section
			 4123.511 of the Revised
			 Code.
(B) The appendix to this rule
			 shall constitute the complete list of medications, and the maximum quantity of
			 such medications, that are approved for reimbursement by the bureau for first
			 fill prior to issuance of an initial determination order. Except as otherwise
			 provided in paragraph (C) of this rule, drugs not listed in the appendix to
			 this rule are not eligible for reimbursement by the bureau under the first fill
			 program.
(C) Notwithstanding
			 paragraph (B) of this rule, in cases of medical necessity supported by clinical
			 documentation and evidence of need the bureau may, with prior authorization,
			 reimburse for the first fill of medications that are eligible for reimbursement
			 under rule
			 4123-6-21.3 of the
			 Administrative Code but are not listed in the appendix to this rule.
(D) Reimbursement of outpatient medications
			 by the bureau under the first fill program shall be subject to the following
			 limitations:
(1) Approval for reimbursement of
			 medications under the first fill program will be limited to the quantity limits
			 listed in the appendix to this rule, and no refills will be approved;
(2) With the exception of antivirals,
			 antiretrovirals, and antibiotics, approval for reimbursement of medications
			 under the first fill program will be limited to one drug per therapeutic drug
			 class listed in the appendix to the rule;
(3) Extemporaneous compounded prescriptions
			 are not eligible for reimbursement by the bureau under the first fill
			 program.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-21.7 - Reimbursement of opioids in the treatment of pain for a work related injury or occupational disease

Current through all regulations passed and filed through July 1, 2024
This rule governs the bureau's
				reimbursement of opioid prescriptions used to treat acute, subacute, and
				chronic pain in a work related injury or occupational disease.
(A)
								Definitions.
For purposes of this rule:
(1)
									"Acute pain,"
			 "chronic pain," "morphine equivalent dose (MED)," and "subacute pain" have the
			 same meanings as defined in rule
			 4731-11-01 of the
			 Administrative Code.
(2)
									"OARRS" means the "Ohio Automated Rx Reporting System"
			 drug database established and maintained pursuant to section
			 4729.75 of the Revised
			 Code.
(3)
									"Opioid" has the same meaning as "opioid analgesic" as
			 defined in section 3719.01 of the Revised
			 Code.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-21.8 - Reimbursement for services to assist in the discontinuation of medications

Current through all regulations passed and filed through July 1, 2024
This rule governs the bureau's
				reimbursement for services to aid injured workers in discontinuing medications
				which may be necessary and appropriate in the treatment of work related
				injuries, but which may increase the risk of dependency, misuse, and substance
				use disorder in some injured workers if continued. Medically necessary and
				appropriate services to aid injured workers in discontinuing these medications
				may include services which provide functional restoration and pharmacologic and
				non-pharmacologic treatment alternatives.
(A)
								Assessment
			 services will be reimbursed when the medical documentation reflects:
(1)
									The injured
			 worker is currently receiving a medication prescribed for and reimbursed in the
			 injured worker's claim;
(2)
									The injured worker has expressed a desire to
			 discontinue the medication(s) and is willing to participate in a treatment
			 program; and
(3)
									The physician of record determines, based on clinical
			 observation and other factors, that a dependency assessment may be
			 appropriate.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-22 - Stakeholders' health care quality assurance advisory committee

Current through all regulations passed and filed through July 1, 2024
The bureau of workers' compensation stakeholders' health care
				quality assurance advisory committee (HCQAAC) was created to advise the
				administrator, the chief of medical services, and the chief medical officer
				with regard to medical quality issues. A list of medical providers, each
				holding a professional license in good standing, who have
				
								expressed an interest in serving on the HCQAAC, and
				who would add credibility and diversity to the mission and goals of the HCQAAC
				shall be developed and maintained by the 
								the bureau. Providers
				may be nominated for inclusion on the list by provider associations and
				organizations including but not limited to: deans of Ohio's allopathic and
				osteopathic medical schools, deans of Ohio's colleges of pharmacy, deans of
				Ohio's dental schools, the dean of the Ohio college of podiatric medicine, the
				Ohio state medical association, the Ohio state osteopathic association, the
				Ohio state chiropractic association, specialty board associations of Ohio, the
				Ohio podiatric medical association, the Ohio psychological association, the
				Ohio dental association, the Ohio pharmacists association, the Ohio hospital
				association, the Ohio state medical board, the Ohio state chiropractic board,
				the Ohio state psychology board, the Ohio state pharmacy board, and the Ohio
				state dental board.
(A) The HCQAAC
			 shall consist of the bureau's chief medical officer, the chief of medical
			 services and not more than thirteen nor less than five voting members
			 representing the diverse group of providers that provide medical care to the
			 injured workers of Ohio as administrated through the bureau. The committee may
			 create any subcommittees that the committee determines are necessary to assist
			 the committee in performing its duties. Any subcommittee recommendations shall
			 be submitted to the HCQAAC committee.
(B) HCQAAC members must meet the following
			 requirements:
(1) Providers must be familiar
			 with issues relating to the treatment of injured workers in the Ohio workers'
			 compensation system.
(2) Providers
			 must possess significant clinical or administrative experience in health care
			 delivery, including but not limited to, medical quality assurance, disease
			 management, and utilization review.
(3) Providers must have experience with and
			 an understanding of the concepts of evidence based medicine as well as
			 contemporary best practices in their respective areas of practice.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-24 - Treatment necessary due to an industrial injury or occupational disease

Current through all regulations passed and filed through July 1, 2024
Medical or other services to be approved for payment must be
				rendered as a direct result of an injury sustained or occupational disease
				contracted by a claimant in the course of and arising out of employment. The
				claim must be allowed by an order of either the bureau of workers' compensation
				or the industrial commission, or have been recognized by a self-insuring
				employer.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-25 - Payment for medical supplies and services

Current through all regulations passed and filed through July 1, 2024
(A) Medical or other services to be approved
			 for payment must be rendered as a 
			 result of an injury sustained or occupational disease contracted by
			 
								an
			 injured worker in the course of and arising out of employment. The claim
			 must be allowed by an order of either the bureau of workers' compensation or
			 the industrial commission, or have been recognized by a self-insuring employer.
Medical supplies and services will be considered for payment
				when they are reasonably related to the work related
				injury, the requested services are reasonably necessary for treatment of the
				work related injury, and the costs of the services are medically
				reasonable. Payment for services rendered to 
									an injured worker shall be paid
				to a health care provider only when the provider has either delivered, rendered
				or supervised the examination, treatment, evaluation or any other medically
				necessary and related services. Provider supervision of services shall comply
				with the requirements of the provider's regulatory board and the centers for
				medicare and medicaid services (CMS), if applicable, for supervision of the
				service, as in effect on the billed date of service, unless otherwise specified
				in the bureau's provider billing and reimbursement manual in effect on the
				billed date of service. By submitting any fee bill to the bureau, in either
				hardcopy or electronic format, the health care provider affirms that medical
				supplies and services have been provided to the 
									injured
				worker as required by this rule.
Providers billing for services rendered shall follow the
				procedures set forth in the bureau's provider billing and reimbursement manual
				in effect on the billed date of service.
(B) Services rendered by health care
			 providers are subject to review for coding requirements outlined in paragraph
			 (C) of this rule. Payments to health care providers may be adjusted based upon
			 these guidelines.
(C) Coding
			 systems.
(1) Billing codes.
(a) Practitioners are required to use the
			 edition of the CMS healthcare common procedure
			 coding system (HCPCS) in effect on the billed date of service to indicate the
			 procedure or service rendered to injured workers.
(b) Inpatient and outpatient hospital
			 services must be billed using the national uniform billing committee's revenue
			 center codes in effect on the billed date of service (date of discharge for
			 inpatient services).
(c) To insure accurate
			 data collection, the bureau shall adopt a standardized coding structure which
			 shall be adopted by any MCO, QHP, or selfinsuring employer.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-26 - Claimant reimbursement

Current through all regulations passed and filed through July 1, 2024
(A) When the claimant or any other person
			 making payment on behalf of the claimant, including a volunteer, pays for
			 medical services or supplies directly to a health care provider and the
			 medical services or supplies meet the
			 criteria in paragraph (B) of rule 4123-6-16.2 of the Administrative Code,
			 the payor shall be reimbursed upon submission of evidence of the receipt and
			 payment for that medical service or supply.
			 Except as otherwise provided in paragraphs (A)(1) and (A)(2) of this rule, the
			 payor will receive no more than the amount that would have been paid to the
			 health care provider as provided by this chapter.
(1) In cases where the payor is the
			 claimant's health insurer, if the claimant seeks reimbursement for an
			 out-of-pocket copayment, the claimant may be reimbursed for the copayment and
			 the claimant's health insurer may be reimbursed up to the amount that would
			 have been paid to the health care provider as provided by this
			 chapter.
(2) In cases where the
			 claimant pays a pharmacy out of pocket for an outpatient medication because the
			 medication is not payable under division (I) of section
			 4123.511
			 of the Revised Code on the date of service, if the medication later becomes
			 payable, the claimant may be reimbursed the full amount of the claimant's
			 out-of-pocket payment.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-27 - Treatment by more than one physician

Current through all regulations passed and filed through July 1, 2024
Medical fees shall not be approved for treatment by more than
				one physician for the same condition over the same period of time, except where
				a consultant, anesthetist, or assistant is required, or where the necessity for
				treatment by a specialist is clearly shown and approved in advance of
				treatment. This rule does not apply in cases of emergency, or where the
				physician of record's approved treatment plan indicates the necessity for
				multidisciplinary services.
Five Year Review (FYR) Dates:
				08/26/2015 and
				08/25/2020
Promulgated
				Under: 119.03
Statutory
				Authority: 4121.12,
				4121.121,
				4121.30,
				4121.31,
				4121.44,
				4121.441,
				4123.05
Rule
				Amplifies: 4121.12,
				4121.121,
				4121.44,
				4121.441
Prior
				Effective Dates: 2/12/97
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-28 - Treatment of more than one condition or to more than one part of the body

Current through all regulations passed and filed through July 1, 2024
In claims involving treatment of more than one condition or
				more than one part of the body, the attending physician must report all
				conditions and all parts of the body being treated that are affecting the
				length of disability. The conditions submitted shall include a primary
				international classification of disease diagnosis code and a description of the
				condition being treated. This information may be used in the determination of
				the extent of disability resulting from the industrial injury or occupational
				disease.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-29 - Request for information by the treating provider

Current through all regulations passed and filed through July 1, 2024
A provider treating an injured worker may, at any time, make a
				request in writing, 
								facsimile, or
				e-mail, 
								in accordance with the bureau's confidentiality and
				sensitive data requirements, for relevant information concerning
				conditions, treatment or history for the claim. The request for information
				shall be accompanied by an appropriate patient release of medical information.
				A prompt response will be given to this request.
Five Year Review (FYR) Dates:
				08/26/2015 and
				08/25/2020
Promulgated
				Under: 119.03
Statutory
				Authority: 4121.12,
				4121.121,
				4121.30,
				4121.31,
				4121.44,
				4121.441,
				4123.05
Rule
				Amplifies: 4121.12,
				4121.121,
				4121.44,
				4121.441
Prior
				Effective Dates: 2/12/97, 2/14/05
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-30 - Payment for physical medicine

Current through all regulations passed and filed through July 1, 2024
(A) "Physical medicine" is the evaluation and
			 treatment of 
								an injured worker by physical measures and the
			 use of rehabilitative procedures, with or without assistive devices, for the
			 purpose of preventing, correcting, or alleviating any work related disability.
			 Physical medicine includes the establishment and modification of physical
			 rehabilitation programs, treatment planning, instruction, and consultative
			 services. "Physical measures" include massage, heat, cold, air, light, water,
			 electricity, sound, manipulation, and the performance of tests of neuromuscular
			 function as an aid to such treatment. Physical medicine does not include the
			 diagnosis of a patient's disability, the use of roentgen rays or radium for
			 diagnostic or therapeutic purposes, or the use of electricity for cauterization
			 or other surgical purposes. Physical medicine includes, but not limited to,
			 chiropractic treatments, physiotherapy, and physical therapy.
(B) Physical medicine must be prescribed by
			 the physician of record or other approved treating provider licensed to
			 practice medicine, osteopathy, chiropractic, mechanotherapy, dentistry,
			 podiatry, or a certified registered nurse anesthetist,
			 nursing clinical nurse specialist, certified nurse midwife,
			  certified nurse practitioner, or
			  physician
			 assistant. Physical medicine may be provided in the physician's office or
			 referred to another licensed provider.
(C) To be eligible for reimbursement,
			 physical medicine services must be provided by a physician
								or chiropractic
			 physician, or a physical therapist, occupational
			 therapist, massage therapist, athletic trainer,
			 or other qualified non-physician provider practicing within the scope of
			 
								their license, certification, or
			 registration.
(D) Fees for up to
			 twelve physical medicine treatments within sixty days following the date of
			 injury may be reimbursed without prior authorization, provided the treatments
			 are for allowed soft tissue and musculoskeletal conditions in allowed claims
			 and the criteria set forth in paragraphs (B)(1) to (B)(3) of rule 4123-6-16.2
			 of the Administrative Code are met. Otherwise, physical medicine treatment must
			 be prior authorized.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-31 - Payment for miscellaneous medical services and supplies

Current through all regulations passed and filed through July 1, 2024
(A)
			 Acupuncture.
Acupuncture is eligible for
				reimbursement when prior authorized and administered by a licensed doctor of
				medicine, doctor of osteopathic medicine and surgery, or doctor of podiatric
				medicine, a doctor of chiropractic who holds a certificate to practice
				acupuncture from the Ohio state chiropractic board, or a non-physician
				acupuncturist licensed pursuant to and practicing in compliance with Chapter
				4762. of the Revised Code.
(B) Orthotic devices.
(1) Payment is made only for those orthotic
			 devices prescribed in writing by the physician of record or treating physician
			 for treatment of an allowed injury or occupational disease.
(2) Orthotic devices
			 
									are
			 eligible for reimbursement only when custom fitted or custom fabricated
			 and delivered to the satisfaction of the prescribing physician and the
			 administrative agencies. Repairs, modifications, and adjustments to secure
			 satisfactory application of the orthotic appliance 
									will be made
			 within sixty days of fitting and application without additional charge by the
			 supplier of the orthotic device.
(3)
									Measurement, transportation, or other expenses
			 incurred by the supplier-orthotist are not eligible for
			 reimbursement, except when the supplier-orthotist
			 
									needs to travel beyond the limits of the metropolitan
			 community in which 
									they maintain their place of business by reason
			 of the physical incapacity of the claimant or by reason of direct prescription
			 by the attending physician. The supplier-orthotist 
									in those
			 circumstances will be paid for traveling expenses on a round-trip
			 basis
									when separately specified on the
			 supplier-orthotist's billing, including the points of travel and the name of
			 the physician prescribing the travel. Payment will be made for a maximum of
			 three round-trip calls.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-32 - Payment for lumbar fusion surgery

Current through all regulations passed and filed through July 1, 2024
Reimbursement for lumbar
				fusion surgery for treatment of allowed conditions in a claim resulting from an
				allowed industrial injury or occupational disease shall be limited to claims in
				which current best medical practices as implemented by this rule are
				followed.
This rule governs the bureau's reimbursement of lumbar fusion
				surgery to treat a work related injury or occupational disease. It is not meant
				to preclude, or substitute for, the surgeon's responsibility to exercise sound
				clinical judgment in light of current best medical practices when treating
				injured workers.
A provider's failure to comply with the requirements of this
				rule may constitute endangerment to the health and safety of injured workers,
				and claims involving lumbar fusion surgery not in compliance with this rule may
				be subject to peer review by the bureau of workers' compensation stakeholders'
				health care quality assurance advisory committee (HCQAAC) pursuant to rule
				4123-6-22
				of the Administrative Code or other peer review committee established by the
				bureau.
Medical treatment reimbursement requests (on form C-9 or
				equivalent) for lumbar fusion surgery are not subject to dismissal by the MCO
				pursuant to paragraph (F)(7) of rule 4123-6-16.2 of the Administrative
				Code.
(A) Prerequisites to
			 consideration of lumbar fusion surgery.
Except as otherwise provided in paragraph (A)(4) of this rule,
				authorization for lumbar fusion shall be considered only in cases in which the
				following criteria are met:
(1)
			 Conservative care.
(a) The injured worker must
			 have had at least sixty days of conservative care for low back pain, with an
			 emphasis on:
(i) Physical
			 reconditioning;
(ii) Avoidance of
			 opioids, when possible; and
(iii)
			 Avoidance of provider catastrophizing the explanation of lumbar MRI
			 findings.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-33 - Payment for health and behavior assessment and intervention services

Current through all regulations passed and filed through July 1, 2024
This rule governs the bureau's reimbursement for health
				 behavior assessment and intervention
				(HBAI) services offered to injured workers who may benefit from an assessment
				that focuses on identifying behavioral barriers impeding the injured worker's
				recovery which may be addressed through intervention services.
(A) An injured worker shall be eligible for
			 consideration of 
								HBAI services if the
			 injured worker has the capacity to understand and respond meaningfully during
			 the health  behavior assessment process
			 and:
(1) The injured worker's physician of
			 record determines:
(a) The injured worker is
			 not progressing with their injury after the initial course of treatment;
			 and
(b) The injured worker's
			 healing appears to be delayed due to behavioral barriers; or
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-34 - Payment for treatment of concussion injuries

Current through all regulations passed and filed through July 1, 2024
This rule governs the bureau's
				reimbursement for services in an allowed claim related to concussion. It is not
				meant to preclude, or substitute for, the health care provider's responsibility
				to exercise sound clinical judgment in light of current best medical practices
				when treating injured workers.
(A)
								As used in this
			 rule, "concussion" means a type of traumatic brain injury induced by external
			 force, which might include a bump or blow to the head, or a jolt or hit to the
			 body, which causes the brain to bounce around or twist in the skull, causing
			 chemical changes in the brain and sometimes stretching and damaging brain
			 cells.
(1)
									Concussion is manifest by at least one of the
			 following:
(a)
										Any alteration in mental state at the time of the accident
			 (feeling dazed, disoriented, or confused);
(b)
										Any period of
			 loss of consciousness;
(c)
										Any loss of memory for events immediately before or
			 after the accident; or
(d)
										Focal neurological deficit that may or may not be
			 transient, but where the severity of the injury does not exceed the
			 following:
(i)
											A loss of consciousness for approximately thirty minutes or
			 less;
(ii)After thirty minutes, an initial Glasgow Coma Score of
			 13-15; or
(iii)Post-traumatic amnesia not greater than twenty-four
			 hours.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-35 - Payment for spinal cord stimulator

Current through all regulations passed and filed through July 1, 2024
Reimbursement for a spinal cord
				stimulator for treatment of allowed conditions in a claim resulting from an
				allowed work related injury or occupational disease is limited to claims in
				which current best medical practices as implemented by this rule are
				followed.
This rule governs the bureau's
				reimbursement of a spinal cord stimulator to treat a work related injury or
				occupational disease. It is not meant to preclude, or substitute for, the
				treating physician's responsibility to exercise sound clinical judgment in
				light of current best medical practices when treating injured
				workers.
A provider's failure to comply with
				this rule may constitute endangerment to the health and safety of injured
				workers, and claims involving a spinal cord stimulator not in compliance with
				this rule may be subject to peer review by the bureau of workers' compensation
				stakeholders' health care quality assurance advisory committee (HCQAAC)
				pursuant to rule
				4123-6-22
				of the Administrative Code or other peer review committee established by the
				bureau.
Medical treatment reimbursement
				requests (on form C-9 or equivalent) for a spinal cord stimulator are not
				subject to dismissal by the MCO pursuant to paragraph (F)(7) of rule
				4123-6-16.2 of the Administrative Code.
(A)
								Authorization for
			 a spinal cord stimulator will be considered only in cases in which the
			 following criteria are met:
(1)
									Allowed conditions. The injured worker has one or more
			 of the following conditions allowed in their claim:
(a)
										Failed thoracic
			 or lumbar spinal surgery.
(b)
										Complex regional pain syndrome.
(c)
										Non-operable
			 peripheral vascular disease/limb ischemia.
(d)
										Neuropathic pain
			 post-thoracic or post-lumbar surgery.
(e)
										Chronic thoracic
			 or lumbar radiculopathy.
(f)
										Spinal cord injury dysesthesias.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-36 - Enhanced care program

Current through all regulations passed and filed through July 1, 2024
This rule governs the bureau's enhanced
				care program for injured workers who have sustained a compensable knee injury.
				The program is designed to simplify the claims management process and encourage
				higher quality, better coordinated care for eligible claims that results in
				improved outcomes.
(A)
								Notwithstanding any provision to the contrary in any
			 other rule of the bureau, the administrator may, for purposes of the enhanced
			 care program, allow one or more managed care organizations to authorize medical
			 treatment reimbursement requests for the first sixty days from the initial
			 allowance of an eligible claim for any conditions within the same knee as the
			 conditions initially allowed in the claim, and presumed to be causally related
			 to the same industrial injury or occupational disease, without disclaimer,
			 during such time as the conditions for which treatment reimbursement is
			 authorized but which are not yet allowed are being considered for allowance or
			 being adjudicated.
(B)
								Claims meeting the following criteria are eligible for
			 inclusion in the enhanced care program:
(1)
									The injured
			 worker's claim is a work-related knee only injury as documented by the medical
			 evidence in the claim, and is allowed for knee conditions only;
(2)
									The injured
			 worker's physician of record is certified to participate in the HPP, and has
			 signed and agrees to comply with the "Enhanced Care Program Provider Addendum"
			 to the provider certification application and agreement or recertification
			 application and agreement, in accordance with rule
			 4123-6-02.3 of the Administrative Code;
			 and
(3)
									The injured worker's employer of record is not:
(a)
										A state agency;
			 or
(b)
										A self-insuring employer providing compensation and
			 benefits pursuant to section
			 4123.35 of the Revised
			 Code.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-37 - Payment of hospital bills

Current through all regulations passed and filed through July 1, 2024
(A) Direct reimbursement will not be made to
			 members of a hospital resident staff.
(B) Payment for personal comfort items, which
			 include, but are not limited to, telephones, television, and private rooms
			 provided at the patient's request, are not compensable.
(C) Bureau fees for hospital inpatient
			 services.
(1) Bureau fees for hospital
			 inpatient services will be based on usual and customary methods of payment,
			 such as prospective payment systems, including diagnosis related groups (DRG),
			 per diem rates, rates based on hospital cost to charge ratios or percent of
			 allowed charges.
(2) Except in
			 cases of emergency, prior authorization must be obtained in advance of all
			 hospitalizations. The hospital must notify the bureau, the injured worker's
			 MCO, QHP, or self-insuring employer of emergency inpatient admissions within
			 one business day of the admission. Failure to comply with this rule shall be
			 sufficient ground for denial of room and board charges by the bureau, MCO, QHP,
			 or self-insuring employer from the date of admission up to the actual date of
			 notification. Room and board charges denied pursuant to this rule may not be
			 billed to the injured worker.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-37.1 - Payment of hospital inpatient services

Current through all regulations passed and filed through July 1, 2024
(A)
			 HPP.
Except as provided in paragraphs (A)(7) and (A)(8) of this
				rule, reimbursement for hospital inpatient services with a discharge date of
				February 1, 2024 or after will be calculated as follows:
(1)
(a)
			 Reimbursement for hospital inpatient services, other than outliers as defined
			 in paragraph (A)(3) of this rule, services provided by hospitals subject to
			 reimbursement under paragraph (A)(4) of this rule, or acute or subacute
			 inpatient detoxification services subject to reimbursement on a per diem basis
			 under paragraph (A)(7) of this rule, will be calculated using the applicable
			 medicare severity diagnosis related group (MS- DRG) reimbursement rate for the
			 hospital inpatient service under the medicare inpatient prospective payment
			 system multiplied by a payment adjustment factor of 1.181 plus a new technology
			 add-on payment (if applicable), according to the following formula:
MS-DRG reimbursement rate x 1.181 + new technology add-on
				payment (if applicable) = bureau reimbursement for hospital inpatient
				service.
(b) In the event
			 the centers for medicare and medicaid services makes subsequent adjustments to
			 the medicare reimbursement rates under the medicare inpatient prospective
			 payment system as implemented by the materials specified in paragraph (A)(10)
			 of this rule other than technical corrections, including but not limited to
			 adjustments related to federal budget sequestration pursuant to the Budget
			 Control Act of 2011, 125 Stat. 239,
			 2 U.S.C.
			 900 to
			 907d as amended as of the effective
			 date of this rule, the "applicable medicare severity diagnosis related group
			 (MS-DRG) reimbursement rate for the hospital inpatient service under the
			 medicare inpatient prospective payment system" as specified in this paragraph
			 will be determined by the bureau without regard to such subsequent
			 adjustments.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-37.3 - Payment of ambulatory surgical center services

Current through all regulations passed and filed through July 1, 2024
Unless an MCO has negotiated a different payment rate with an
				ambulatory surgical center pursuant to rule
				4123-6-10 of the Administrative
				Code, reimbursement for ambulatory surgical center services with a date of
				service of May 1, 2024 or after will be equal to the lesser of the
				ambulatory surgical center's allowable billed charges or the fee schedule
				amount indicated in the appendix to this rule, developed with provider and
				employer input and effective May 1, 2024.
Ambulatory surgical centers determined as of the effective date
				of this rule by the centers for medicare and medicaid services (CMS) to not
				meet quality measures for the calendar year 2024 full payment
				update under the CMS ambulatory surgical center quality reporting (ASCQR)
				program, established by 42
				U.S.C. 1395l as in effect as of the effective
				date of this rule and 42 C.F.R. Part 416, Subpart H as published in the October
				1,
				2023 Code of Federal Regulations, will be subject to a two per cent
				reduction to the BWC 2024 ambulatory surgical center fee schedule amounts
				indicated in the appendix to this rule.
However, if such an ambulatory surgical center, upon
				reconsideration, is subsequently determined by CMS to meet quality measures for
				the calendar year 2024 full payment update under the CMS ASCQR program,
				upon the ambulatory surgical center's request the ambulatory surgical center
				will no longer be subject to the two per cent reduction, and the bureau will
				adjust any bills for dates of service on or after the effective date of this
				rule that were previously reduced pursuant to this rule.
Click to
				view Appendix
Click to
				view Appendix
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-38 - Payment for home health nursing services and home health aide services

Current through all regulations passed and filed through July 1, 2024
(A)
								Except as provided in rule 4123-6-38.1 of the
			 Administrative Code, home health nursing services and home health aide services
			 shall be provided by registered nurses or licensed practical nurses and home
			 health aides employed by a home health agency meeting the qualifications
			 specified in paragraph (C) of rule 4123-6-02.2 of the Administrative
			 Code.
(B)
								Authorization for home health nursing services and home
			 health aide services.
(1)
									Authorization for home health nursing services will be
			 considered only in cases where, as the result of an allowed injury or
			 occupational disease:
(a)
										The injured worker is mentally or physically incapable
			 of independently performing activities of daily living; or
(b)
										Home health
			 nursing services or home health aide services are ordered for discharge
			 follow-up or by a treating physician as part of a written treatment
			 plan.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-38.1 - Payment for nursing and caregiver services provided by persons other than home health agency employees

Current through all regulations passed and filed through July 1, 2024
(A) Nursing services provided prior to
			 December 14, 1992.
(1) Registered nurses and
			 licensed practical nurses who are not employed by  a home
			 health agency a home health agency
			 certified in accordance with rule 4123-6-02.2 of the Administrative Code
			 may continue to provide authorized services to an injured worker if the
			 services began prior to December 14, 1992.
(2) The need for nursing services must be the
			  result of an allowed injury or
			 occupational disease.
(3) In the
			 event the registered nurse or licensed practical nurse is no longer able to
			 provide approved services or if services are stopped and later restarted,
			 nursing services shall be provided only by an employee of a
			  home health
			 agency
									certified
			 in accordance with rule 4123-6-02.2 of the Administrative Code.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-38.2 - Payment of nursing home and residential care/assisted living services

Current through all regulations passed and filed through July 1, 2024
(A) Payment to a
			 nursing home or residential care/assisted living facility for the care of
			 
								an
			 injured worker who sustained an injury or contracted an occupational
			 disease in the course of and arising out of employment shall be made only when
			 the need for such care is the direct result of the allowed conditions in the
			 claim.
(B) Payment will be made
			 only for care provided in nursing homes and residential care/ assisted living
			 facilities meeting the qualifications specified in paragraph (C) of rule
			 4123-6-02.2 of the Administrative Code.
(C) Nursing home or residential care/assisted
			 living facility care must be pre-authorized, except when a nursing home or
			 residential care/assisted living facility is used immediately following an
			 approved or emergency hospitalization.
(1) The
			 allowed per diem rate for 
									an injured worker shall be no greater than the
			 bureau's fee schedule or the rate negotiated between the nursing home or
			 residential care/assisted living facility and the bureau, MCO, QHP, or
			 selfinsuring employer.
(2) Nursing
			 home care shall be provided on a semiprivate bed basis, unless a situation
			 exists when the use of a private room is medically necessary due to the allowed
			  condition. In these cases, the
			 use of such a private room must be preauthorized, except in cases of emergency,
			 as defined in rule
			 4123-6-01 of the
			 Administrative Code, or where the 
									injured
			 worker's condition would be endangered by delay.
(3)
									Prescription medication provided to an
			 injured worker in a nursing home for the treatment of an allowed injury or
			 occupational disease is included in the nursing home's per diem rate, and is
			 not separately payable.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-39 - Payment for prosthetic device or other artificial appliances

Current through all regulations passed and filed through July 1, 2024
(A) For purposes of
			 this rule:
(1) "Amputee clinic" means an
			 interdisciplinary group of professional providers led by a physician with a
			 specialty in physical medicine and rehabilitation, orthopedic surgery or
			 vascular surgery knowledgeable in the field of prosthetics and physical
			 disabilities, comprised of members that may include a podiatrist, physical
			 therapist, occupational therapist, kinesiotherapist, prosthetist and other
			 medical specialists that serves individuals requiring prosthetic
			 devices.
(2) "Artificial appliance"
			 means any item that replaces a body part or function of a body part of an
			 injured worker who has received a scheduled loss or facial disfigurement award
			 for that body part under division (B) of section
			 4123.57
			 of the Revised Code, and that the amputee clinic at the Ohio state university
			 medical center, the opportunities for Ohioans with disabilities agency, or a
			 multidisciplinary amputee clinic or prescribing physician approved by the
			 administrator or the administrator's designee determines is needed by the
			 injured worker. Examples of artificial appliances include, but are not limited
			 to, prosthetic devices, artificial eyes, wheelchairs, canes, crutches, walkers,
			 braces, etc.
(3) "Prosthetic
			 device" means a custom fabricated or fitted medical device that is a type of
			 artificial appliance used to replace a missing appendage or other external body
			 part. It includes an artificial limb, hand, or foot, but does not include
			 devices implanted into the body by a physician, artificial eyes, intraocular
			 lenses, dental appliances, ostomy products, cosmetic devices such as breast
			 prostheses, eyelashes, wigs, or other devices that do not have a significant
			 impact on the musculoskeletal functions of the body.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-40 - Payment of injured worker travel expenses

Current through all regulations passed and filed through July 1, 2024
(A)
								
								An injured worker's reasonable and
			 necessary travel expenses shall be paid, upon the filing of a proper
			 request, under the following circumstances:
(1) When the 
									injured
			 worker has been ordered or authorized to undergo a medical examination
			 outside of the city or community limits where he resides. The
			 
									injured
			 worker shall be reimbursed for travel only if the travel distance exceeds
			 forty-five miles
			 round trip.
(2) When
			 treatment necessary for the allowed 
									work
			 related condition cannot be obtained within the city or community where
			 the 
									injured worker resides, and the treatment has been
			 pre-authorized and approved. The injured worker shall be reimbursed for
			 travel only if the travel distance exceeds forty-five miles round trip.
(3) When the 
									injured
			 worker's allowed conditions require taxicab or other special
			 transportation for treatment or examination on account of an allowed injury or
			 occupational disease. Taxicab or other special transportation must be
			 pre-authorized.
(4)
									When travel expenses are authorized as part of an
			 approved vocational rehabilitation assessment plan, comprehensive vocational
			 rehabilitation plan, or job retention plan pursuant to rule
			 4123-18-08
			 of the Administrative Code.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-41 - No legal relationship between the industrial commission or bureau and a health care provider

Current through all regulations passed and filed through July 1, 2024
(A) Direct payment to a health care provider
			 or other person by the industrial commission, self-insuring employer, bureau of
			 workers' compensation, or their agent, for medical care rendered to
			 
								an
			 injured worker does not imply or create a legal relationship between the
			 provider or person and the commission, self-insuring employer, bureau, or their
			 agent.
(B) The services rendered to
			 the 
								injured worker are the legal obligation of the
			 injured
			 worker. The direct payment to the health care provider is a discretionary
			 method by which the award made to the 
								injured
			 worker for medical expenses may be discharged.
(C) Except as prohibited by division (O) of
			 section
			 4121.44
			 of the Revised Code, when payment is made to the injured
			 worker, the sole legal recourse of the health care provider is against
			 the injured
			 worker.
Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-42 - Interest on late payments for equipment, materials, goods, supplies or services in state insurance fund, public work relief employees' compensation fund, coal workers pneumoconiosis fund, and marine industry fund claims

Current through all regulations passed and filed through July 1, 2024
(A) Payment is made
			 for equipment, materials, goods, supplies, or services incurred by the claimant
			 in connection with claims against the state insurance fund,
			 public work relief employees' compensation fund, coal
			 workers pneumoconiosis fund, or marine industry fund
			 
								in
			 accordance with section
			 126.30 of the Revised Code. For
			 the purpose of this rule, the required payment date is the date on which
			 payment is due under the terms of a written agreement between the bureau, or
			 its agent, and the provider. Payment will be made either thirty days after the
			 bureau, or its agent, receives a proper invoice for the amount of the payment
			 due, or thirty days after the final adjudication allowing payment of an award
			 to the claimant, whichever is later.
(1) A
			 "proper invoice" includes but is not limited to the claimant's name, claim
			 number, date of injury or occupational disease, employer's name, provider's
			 name and address and assigned payee number, a description of the service
			 provided, the procedure code for the service provided, the date provided, and
			 the amount of the charge. If more than one item has been included in the
			 invoice, each item is to be considered separately to determine if it is a
			 proper invoice.
(2) If the bureau
			 or its agent determines that an invoice is improper, the bureau or its agent
			 shall send notification to the provider through the MCO
			  at least fifteen days prior to what
			 would be the required payment date if the invoice did not contain an error. The
			 notice shall describe the error and the additional information needed to
			 correct the error. The required payment date shall be redetermined upon receipt
			 of a proper invoice.
(3) If an
			 invoice is for payment of either a condition not allowed in a claim, or for a
			 claim that is not allowed, the payment date is thirty days after final
			 adjudication of allowance of the condition or claim. As defined in section
			 126.30 of the Revised Code,
			 "final adjudication" is the date that the decision of the bureau,
			 industrial commission, or court becomes final,
			 with no further right of appeal. If any section of the Revised Code contains a
			 faster timetable for payments, however, such provisions shall not be superseded
			 by this rule.