Current through all regulations passed and filed through September 16, 2024
(A) Pursuant to division (A)(1) of section
4121.441 of the Revised Code,
this rule provides procedures for an alternative dispute
resolution (ADR) process for medical disputes between an employer, an injured
worker, or a provider and an MCO arising from the MCO's decision regarding a
medical treatment reimbursement request (on form C-9 or equivalent). An injured
worker or employer must exhaust the ADR procedures of this rule prior to filing
an appeal under section
4123.511 of the Revised Code on
an MCO's decision regarding a medical treatment reimbursement
request.
(B) Within fourteen days
of receipt of an MCO decision, an injured worker, employer, or provider may
dispute the decision in writing (on form C-11 or equivalent) to the MCO. The
written medical dispute must contain, at a minimum, the following elements:
(1) Injured worker name.
(2) Injured worker claim number.
(3) Date of initial medical treatment
reimbursement request in dispute.
(4) Specific issue(s) in dispute, including
description, frequency/duration, beginning/ending dates, and type of
treatment/service/body part.
(5)
Name of party making written appeal request.
(6) Signature of party making written appeal
request or the party's authorized representative.
Written medical disputes that do not contain the minimum
elements set forth in this paragraph may be dismissed by the MCO or
bureau.
(C) Upon
receipt of a written medical dispute, the MCO will initiate
the ADR process,which consists of one
independent level of professional review ("peer
review") as follows:
(1) If an
individual health care provider eligible to be physician of record would be
providing the services requested in the dispute, the
peer review
is to be
conducted by an individual or individuals licensed pursuant to the same section
of the Revised Code as the health care provider who would be providing the
services requested.
(2)
Notwithstanding paragraph (C)(1) of this rule, if the MCO has already obtained
one or more peer reviews during previous disputes involving the same
treatment, the MCO may obtain a
different perspective review from a licensed physician who falls outside the
peer review criteria set forth in this paragraph.
(3) If an individual health care provider not
eligible to be physician of record would be providing the services requested in
the dispute,
peer
review
is to be conducted by an individual or
individuals eligible to be physician of record whose scope of practice includes
the services requested.
(4) If the
MCO receives a dispute where the requested treatment
is the
same as a previous treatment
request for which the MCO conducted a
peer
review, and the previous treatment request was ultimately denied based on the
peer review, the MCO may use the previous
peer review
as the
peer review
under
this paragraph, provided the peer review was conducted
within six months of the current request and there are no new or changed
circumstances in the injured worker's condition documented in the claim
file.
(5) The MCO
will
submit a copy of the
peer review to the bureau, and the bureau
will
provide the parties to the claim access to the
peer
review electronically.
(D) If, upon consideration of additional
evidence or after agreement with the party that submitted the written medical
dispute, the MCO reverses the decision under dispute or otherwise resolves the
dispute to the satisfaction of the party, the MCO may issue a new decision and
dismiss the dispute.
(E)
The MCO
will complete the ADR process and submit its
recommended ADR decision to the bureau electronically within twenty-one days of
the MCO's receipt of the written medical dispute,
unless the injured worker is scheduled for an independent medical
examination under paragraph (I) of this rule.
(F) Within two business days after receipt of
a recommended ADR decision from the MCO, the bureau
will publish
and mail to all parties a final order, which may be appealed to the industrial commission
pursuant to section 4123.511 of the Revised Code.
The provider and the MCO may not file an appeal of the bureau order.
(G) Notwithstanding paragraph (C) of this
rule, the MCO may pend a written medical dispute under the following
circumstances:
(1) If the MCO receives a
written medical dispute involving a medical treatment reimbursement request
that
is the same as a previous treatment request for which the MCO conducted a
peer
review, and the previous treatment request is pending before the bureau or
industrial commission, the MCO may pend the new dispute until the previous
treatment request has been resolved. Once the previous treatment request has
been resolved, the MCO
will resume the ADR process.
(2) If the MCO receives a written medical
dispute involving a medical treatment reimbursement request
that is
dependent
upon the outcome of an additional condition
request
pending before the bureau or industrial commission, the MCO may pend the
dispute until the earlier of the final administrative or judicial decision or
the industrial commission staff hearing officer decision on the
request for the additional condition, at which time
the MCO
will resume the ADR process.
(H) Notwithstanding paragraph (C) of this
rule, an MCO may submit its recommended ADR decision to the bureau
electronically without obtaining
a peer review
under the following circumstances:
(1) The MCO
receives a written medical dispute involving a medical treatment reimbursement
request relating to the delivery of medical services that have been approved by
the MCO pursuant to standard treatment guidelines, pathways, or presumptive
authorization guidelines.
(2) The
MCO receives a written medical dispute involving a medical treatment
reimbursement request clearly relating to the
delivery of medical services for a condition that is not allowed in the claim,
and the issue of the allowance of the additional condition is not pending
before the bureau or industrial commission.
(I) Either the MCO or the bureau may schedule
an independent medical examination (IME) of the
injured
worker to assist in the ADR process under this rule.
(1) An ADR IME will be limited to issues
relating to medical treatment disputes, and will not include extent of
disability issues. An ADR IME will not be conducted at the request of an
employer and does not substitute for an examination permitted under section
4123.651 of the Revised
Code.
(2) If an ADR IME is
scheduled under this rule, the parties, and their representatives, if any, will
be promptly notified as to the time and place of the examination, and the
questions and information provided to the doctor. The injured worker will be reimbursed for travel expenses in
accordance with rule
4123-6-40 of the Administrative
Code.
(3)
The scheduling of an ADR IME will toll the MCO's time frame
for completing the ADR process, and in such cases the MCO will submit its
recommended ADR decision to the bureau electronically within seven days after
receipt of the independent medical examination report.
(4) If
an injured worker refuses to attend an IME to assist in the ADR process, the
MCO will refer the issue to the bureau, and the injured worker's right to
benefits may be suspended during the period of refusal.
