Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-01 - Definitions

Current through all regulations passed and filed through July 1, 2024
As used in this chapter:
(A) "Authorization" or "prior authorization"
			 means:
Notification  that a specific treatment, service, or equipment is
				medically necessary for the diagnosis or treatment of an allowed condition.
(B) "Bureau certified provider"
			 means:
A  provider who
				is approved by the bureau for participation in the health partnership program
				
									(HPP)
				pursuant to this chapter of Administrative Code.
(C) "Certification" or "recertification"
			 means:
A process by which the bureau approves a provider or
				managed care organization (MCO) for participation in the HPP.
(D) "Credentialing" or "recredentialing"
			 means:
A process by which the bureau validates or reviews the
				completed and signed application of a provider for certification or
				recertification.
(E)
			 "Dispute resolution" means:
Procedures for the resolution of medical disputes prior to
				filing an appeal under section
				4123.511
				of the Revised Code.
(F)
			 "Emergency" means:
Medical services that are required for the immediate diagnosis
				and treatment of a condition that, if not immediately diagnosed and treated,
				could lead to serious physical or mental disability or death, or that are
				immediately necessary to alleviate severe pain. Emergency treatment includes
				treatment delivered in response to symptoms that may or may not represent an
				actual emergency, but is necessary to determine whether an emergency
				exists.
(G) "Employee"
			 means:
As used in the rules of this chapter, the term "employee"
				includes the terms "injured worker" and "claimant" and all employees of
				employers covered under HPP.
(H) "Health care
			 provider" or "provider" means:
A physician or practitioner, or any person, firm, corporation,
				limited liability corporation, partnership, association, agency, institution,
				or other legal entity licensed, certified, or approved by a professional
				standard-setting body or by medicare or medicaid to provide medical services or
				supplies to an injured worker, including a qualified
				vocational rehabilitation provider.
(I) "Health partnership program" or "HPP" means:
The bureau of workers' compensation's comprehensive managed
				care program under the direction of the chief of medical services as provided
				in sections
				4121.44
				and
				4121.441
				of the Revised Code.
(J) "Hospital" means:
An institution that provides facilities for surgical and
				medical diagnosis and treatment of bed patients under the supervision of staff
				physicians and furnishes twenty-four hour-a-day care by registered
				nurses.
(1) For the purposes of this
			 chapter relating to hospitals, "inpatient" means:
An injured worker is considered to be an inpatient when he or
				she has been admitted to a hospital for bed occupancy for purposes of receiving
				inpatient hospital services. An injured worker is considered an inpatient if
				there is a formal order for admission from the physician. The determination of
				an inpatient stay is not based upon the number of hours involved. If it later
				develops during the uninterrupted stay that the injured worker is discharged,
				transferred to another inpatient unit within the hospital, transferred to
				another hospital, transferred to another state psychiatric facility or expires
				and does not actually use a bed overnight, the order from the attending
				physician addressing the type of encounter will define the status of the
				stay.
(2) For the purposes
			 of this chapter relating to hospitals, "outpatient" means:
The injured worker is not receiving inpatient care, as
				"inpatient" is defined in paragraph (J)(1) of this
				rule, but receives outpatient services at a hospital. An outpatient encounter
				cannot exceed seventy-two hours of uninterrupted duration.