Current through all regulations passed and filed through September 16, 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.
(D) The application for certification submitted to the
bureau by the
MCO shall include, at a minimum, the following
information and provisions:
(1) A statement that the application is
without misrepresentation, misstatement, or omission of a relevant fact or
other representations involving dishonesty, fraud, or deceit.
(2) A description of the geographic area of
the state of Ohio for which the
MCO wishes to be certified
by the bureau. The minimum geographic area
is a county. The bureau shall certify
MCO participation on a county basis. The
MCO may apply for
coverage in more than one county or statewide.
(3) A description of the
MCO that includes, but is not limited to, a
profile that includes a disclosure statement regarding the
MCO's organizational structure, including
subsidiary, parent and affiliate relationships, together with historical and
current data. The
MCO must identify its principals; provide the
MCO's date of incorporation or formation of
partnership, or limited liability company, or business trust; provide any trade
names or fictitious names the
MCO is, or has been, doing
business under; provide the number of years the
MCO has operated in Ohio; identify other states in
which the
MCO is doing business or has done business;
provide a table of organization with the number of employees; and identify any
banking relationships, including all account information with any financial
institutions.
(4) A description of
the
MCO's business continuity plan.
(5) A description of the bureau approved
treatment guidelines used by the MCO, including a description
of how the
MCO shall implement the treatment
guidelines.
(6) A description of
the
MCO's utilization review process.
(7) A description of the
MCO's quality assurance/ improvement standards
program and process, including the use of satisfaction surveys.
(8) A description of the
MCO's medical dispute resolution process that
meets the requirements of rule
4123-6-16 of the Administrative
Code.
(9) A description of the
MCO's administrative and bill payment grievance
processes.
(10) A description of
the
MCO's information system platforms, capabilities
and capacities; a description of the
MCO's system for
reporting necessary data elements, including but not limited to those required
for performance measurements; and the
MCO's measures in place
to ensure data security, including back-up systems.
(11) A description of the
MCO's medical case management policies and
procedures.
(12) A description of
the
MCO's policies and procedures regarding the
protection of confidential and sensitive records.
(13) A description of the
MCO's policies and procedures regarding retention
of information.
(14) A description
of the
MCO's provider relations and education
program.
(15) A description of the
MCO's employer and employee relations and
education program, including but not limited to a description of methodologies
to be used to explain options available to injured workers, including treatment
by non-network providers and the dispute resolution process.
(16) A description of the
MCO's provider bill payment processes including,
but not limited to, clinical editing software (including review criteria,
process and methodology).
(17)
Attestation of intent to obtain and maintain insurance coverage as required by
the MCO contract, with proof of such coverage to be submitted to the bureau
prior to execution of the contract, and current workers' compensation
coverage.
(18) Attestation of
intent to obtain and maintain professional accreditations as required by the
MCO contract, with proof of such accreditations to be submitted to the bureau
prior to execution of the contract.
(19) A description of any and all individuals
and entities the
MCO is affiliated with (including, but not
limited to, a subcontractor or subcontractee, vendor or vendee, joint venture
or other arrangement), and a copy of the MCO's contract or agreement with each
individual or entity. For purposes of this rule, "affiliated with the MCO"
shall have the same meaning as defined in paragraph (B) of rule
4123-6-03.9 of the
Administrative Code.
(20) Other
descriptions and requirements as contained in divisions (F)(1) to (F)(10) of
section 4121.44 of the Revised
Code.
(E) For MCO
recertification, prior to the expiration of an MCO's certification, the bureau
shall send the certified MCO an application for recertification, which must be
completed and returned to the bureau. The MCO must be able to provide proof of
delivery of the completed application to the bureau upon request. The
application for recertification may be
amended from time to time at the bureau's discretion.
(F) The bureau shall review the application
for certification or recertification submitted by the
MCO. The bureau reserves the right to cross-check data
with other governmental agencies or licensing or accrediting bodies.
(G) During the bureau's review of the
application for certification or recertification, the
MCO shall provide to the bureau any additional
documentation requested and shall permit the bureau, upon request and with
reasonable notice given, to conduct an onsite review of the
MCO.
(H)
an MCO may cure any defects in its application
for certification or recertification within thirty days of notice by the bureau
of such defect in its application.
(I) The bureau may require that the
application be accompanied by an application fee, which shall not exceed the
amount sufficient to cover the cost of processing the application.
(J) The bureau shall hold as confidential and
proprietary information contained in
an MCO's application for
certification or recertification, and other information furnished to the bureau
by
an MCO for purposes of obtaining certification or
to comply with performance and auditing requirements established by the
administrator, in accordance with divisions (H)(1) and (H)(2) of section
4121.44 of the Revised
Code.
(K) The bureau shall not
accept or approve any application for
certification or recertification in which the
MCO proposes to subcontract or outsource medical case
management services, other than as part of the MCO's
business continuity plan as described in paragraph (D)(4) of this rule and
approved by the bureau. However, an MCO may subcontract onsite or
out-of-state medical case management services with the prior approval of the
bureau, provided such services are conducted under the supervision of the
MCO.
