Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-69 - QHP dispute resolution process

Current through all regulations passed and filed through July 1, 2024
(A) This rule shall provide time frames and
			 procedures for review of requests for the delivery of medical services and for
			 the resolution of disputes that may arise between an employee and an employer,
			 an employee and a provider, or an employer and a provider. This rule applies
			 to, but is not limited to, reviews of records, medical disputes arising over
			 issues such as, but not limited to, quality assurance, utilization review, a
			 determination that a service provided to an employee is not covered, is covered
			 or is medically unnecessary; or disputes involving individual health care
			 providers.
(B) Initial review and
			 decision upon requests for the delivery of medical services that include, but
			 are not limited to, medical treatment, major diagnostic testing,
			 hospitalization, surgery and physical therapy, shall be completed by the QHP.
			 The employee, employer and provider shall be notified verbally of the outcome
			 of the initial review within forty-eight hours of the request. Within seven
			 working days of the verbal notification, the verbal notification shall be
			 committed to writing and mailed to the employee, employer and
			 provider.
(C) A QHP shall have a
			 dispute resolution process beyond initial review that includes
			 
								one independent level of professional
			 review.
(D) A QHP dispute
			 resolution process shall be completed and the QHP shall notify the parties to
			 the dispute and their representatives in writing within
			 twenty-one days of the initial written notice of a dispute, unless an
			 extension of time is otherwise agreed to by the parties.
			 
								If the QHP schedules the injured
			 worker for an independent medical examination for the independent level of
			 professional review, the twenty-one day time frame shall be tolled, and in such
			 cases the QHP shall complete the dispute resolution process within seven days
			 after receipt of the independent medical examination report.
(E) The dispute resolution process shall
			 begin upon written notice of the dispute by the party maintaining the dispute
			 to the parties of the dispute.
(1)
									If an
			 individual health care provider 
									eligible to be physician of record would be providing
			 the services requested in the dispute, the independent level of professional
			 review shall consist of a peer review conducted by an individual or individuals
			 licensed pursuant to the same section of the Ohio Revised Code as the health
			 care provider who would be providing the services requested.
(2)
									Notwithstanding
			 paragraph (E)(1) of this rule, if the QHP has already obtained one or more peer
			 reviews during previous disputes involving the same or similar treatment, the
			 QHP may obtain a different perspective review from a licensed physician who
			 falls outside the peer review criteria set forth in
			 thisparagraph.
(3)
									) If an individual health care provider not eligible to
			 be physician of record would be providing the services requested in the
			 dispute, the independent level of professional review shall consist of a
			 provider review conducted by an individual or individuals eligible to be
			 physician of record whose scope of practice includes the services
			 requested.
(4)
									If the QHP receives a dispute where the requested
			 treatment appears to be the same as or similar to a previous treatment request
			 for which the QHP conducted a professional review, and the previous treatment
			 request was ultimately denied based on the professional review, the QHP may use
			 the previous professional review to satisfy the independent level of
			 professional review requirement of this paragraph.