Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-10 - Payment to providers

Current through all regulations passed and filed through July 1, 2024
(A) HPP.
(1) The MCO shall accumulate medical records
			 and bills for services rendered to 
									injured
			 workers for provider services and submit the bills electronically to the
			 bureau for payment in a bureau approved format, utilizing billing policies,
			 including but not limited to clinical editing, as set forth in the MCO
			 contract. The MCO shall submit a bill to the bureau within seven business days
			 of its receipt of a valid, complete bill from the provider.
(2) For a provider in the MCO's panel or with
			 whom the MCO has entered into an arrangement, other than a hospital, the bureau
			 shall electronically transfer to the MCO for payment to the provider, in
			 accordance with rule
			 4123-6-14
			 of the Administrative Code, either the lesser of the bureau fee schedule, the
			 MCO contracted fee, or the charges billed by the provider for the allowed
			 services rendered, or, if applicable under paragraph (A)(7) of this rule, the
			 MCO negotiated fee.
(3) For a
			 bureau certified provider who is not in the MCO's panel or with whom the MCO
			 does not have an arrangement, other than a hospital, the bureau shall
			 electronically transfer to the MCO for payment to the provider, in accordance
			 with rule
			 4123-6-14
			 of the Administrative Code, either the lesser of the bureau fee schedule or the
			 charges billed by the provider for the allowed services rendered, or, if
			 applicable under paragraph (A)(7) of this rule, the MCO negotiated
			 fee.
(4) For a non-bureau certified
			 provider who is not in the MCO's panel or with whom the MCO does not have an
			 arrangement, other than a hospital, the bureau shall electronically transfer to
			 the MCO for payment to the provider for initial or emergency treatment, in
			 accordance with rule
			 4123-6-14
			 of the Administrative Code, either the lesser of the bureau fee schedule or the
			 charges billed by the provider for the allowed services rendered, or, if
			 applicable under paragraph (A)(7) of this rule, the MCO negotiated
			 fee.
(5) For a non-bureau certified
			 provider who is not in the MCO's panel or with whom the MCO does not have an
			 arrangement, other than a hospital, the bureau shall electronically transfer to
			 the MCO for payment to the provider for subsequent treatment after the initial
			 or emergency treatment, in accordance with rule
			 4123-6-14
			 of the Administrative Code, either the lesser of the bureau fee schedule or the
			 charges billed by the provider for the allowed services rendered, or, if
			 applicable under paragraph (A)(7) of this rule, the MCO negotiated fee, only
			 under the following circumstances:
(a) Where
			 the treatment provided by the non-bureau certified provider is not reasonably
			 available through a like bureau certified provider and the MCO has authorized
			 the treatment pursuant to rule 4123-6-06.2 of the Administrative Code,
			 or
(b) Where the treatment provided
			 by the non bureau certified provider is reasonably available through a like
			 bureau certified provider, the non-bureau certified provider may only be
			 reimbursed for the treatment if the provider becomes bureau certified. If the
			 provider refuses or fails to become bureau certified, the treatment shall not
			 be reimbursed.
(6) For
			 hospital services, the bureau shall electronically transfer to the MCO for
			 payment to the hospital, in accordance with rule
			 4123-6-14
			 of the Administrative Code, either the lesser of the applicable amount pursuant
			 to rule 4123-6-37.1(inpatient) or 4123-6- 37.2(outpatient) of the
			 Administrative Code or the MCO contracted fee, or, if applicable under
			 paragraph (A)(7) of this rule, the MCO negotiated fee.
(7) The MCO shall have authority to negotiate
			 fees with providers, either by contract or on a case-by-case basis, in the
			 following circumstances:
(a) As permitted
			 under rule
			 4123-6-08 of
			 the Administrative Code (including the appendix to the rule);
(b) As permitted under rule 4123-6-37.1,
			 4123-6- 37.2 or 4123-6- 37.3 of the Administrative Code;
(c) As permitted under rule
			 4123-18-09
			 of the Administrative Code;
(d)
			 With non-bureau certified providers outside the state, where the treatment
			 provided by the non-bureau certified provider is not reasonably available
			 through a like bureau certified provider;
(e) With bureau certified providers and
			 non-bureau certified providers within the state, where unusual circumstances
			 justify payment above BWC's maximum allowable rate for the centers for medicare
			 and medicaid services' healthcare common procedure coding system (HCPCS) level
			 II and level III coded services/supplies, and such circumstances are documented
			 and approved by the bureau.
(8) The bureau shall not pay for missed
			 appointments or procedures. If the provider customarily charges for missed
			 appointments or procedures, the provider shall inform the
			 
									injured
			 worker upon the initial or emergency treatment that the provider charges
			 for missed appointments or procedures and that such charges are the
			 responsibility of the injured worker. Bills must only contain descriptions
			 of services that have been actually delivered, rendered, or directly supervised
			 by the provider for the actual conditions treated. A provider shall not
			 transmit to the MCO or bureau any bill containing false or misleading
			 information that would cause a provider to receive payment for services that
			 the provider is not entitled to receive.