Chapter 4123-6 | Health Partnership Program

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 …

Unless specifically stated otherwise, the rules of this chapter governing payment of medical services and supplies shall apply to payments to health care providers in all claims for work related injuries or occupational diseases before the bureau, self-insuring employers, MCOs, Q…

Notwithstanding any provision to the contrary in any other rule of the bureau, the administrator may, for purposes of a pilot program, allow one or more managed care organizations to authorize medical treatment reimbursement requests for the first sixty days from the initial allo…

(A) The bureau is authorized to certify a provider who wishes to participate in the HPP. The bureau is authorized to recertify providers as determined by the bureau. The bureau may, but is not required to, recertify providers on a staggered basis, in order of the provider's initi…

(A) The bureau will establish minimum criteria for provider certification. Providers must meet all licensing, certification, or accreditation requirements necessary to provide services in Ohio. A provider licensed, certified, or accredited pursuant to the equivalent law of anothe…

(A) The bureau may enroll non-certified providers eligible under rule 4123-6-06.2 or 4123-6-10 of the Administrative Code or division (N) of section 4121.44 of the Revised Code to receive reimbursement for goods and services provided to injured workers, and for this purpose may r…

(A) To be eligible for participation in the HPP as an ambulatory surgical center arthroplasty center, an ambulatory surgical center must:(1) Be certified as an ambulatory surgical center under paragraph (C) of rule 4123-6-02.2 of the Administrative Code.(2) Have a formal joint re…

(A) The bureau shall make available to each provider a provider certification application and agreement or recertification application and agreement, as applicable, which shall require the provider to furnish documentation as provided in rule 4123-6-02.2 of the Administrative Cod…

(A) The bureau shall initiate the recertification process by sending certified providers notice and a recertification application and agreement, which must be completed, signed, and submitted to the bureau if the provider wishes to be considered for recertification.(B) Except as …

(A) A provider not certified or recertified shall submit any information missing from the provider application and agreement or recertification application and agreement upon request, within thirty days of notice by the bureau. The bureau may deny certification or recertification…

(A) The administrator may refuse to certify or recertify, or may decertify from participation in the HPP, any MCO that:(1) Is owned, directly or indirectly, by an individual or entity that has a felony conviction in any jurisdiction, a conviction under a federal controlled substa…

(A) The bureau shall maintain a public list of bureau certified providers. The bureau shall make the list of bureau certified providers available through the bureau's website.(B) An MCO may, but is not required to, retain a panel of bureau certified providers. A bureau certified …

(A) Except as otherwise provided in paragraph (C) of this rule, the administrator of the bureau of workers' compensation will follow the procedures set forth in this rule to terminate the enrollment of and decertify a non-facility provider who has failed to comply with a workers'…

(A) HPP: Within one business day of initial treatment or initial visit of an injured worker, a provider must report the employee's injury or occupational disease in accordance with either paragraph (A)(1) or (A)(2) of this rule.(1) A provider may report an injury to the MCO respo…

(A) No bureau certified or enrolled provider shall engage in any advertising or solicitation directed to injured workers which is false, fraudulent, deceptive, or misleading.(B) No bureau certified or enrolled provider shall hire, arrange for, or allow any other individual or ent…

No individual who is an officer or employee of an MCO shall represent a claimant or employer in any matter before the industrial commission, the bureau of workers' compensation, or a court of competent jurisdiction. Last updated September 9, 2025 at 11:30 AM Authorized By: 4121.1…

(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 certi…

(A) Upon review by and satisfactory to the bureau that the managed care organization has met bureau certification standards, the bureau shall certify an MCO as eligible to contract with the bureau to provide medical management and cost containment services for injured workers and…

(A) Should the administrator determine that sufficient evidence exists that an MCO has failed to maintain any of the requirements set forth in division (F) of section 4121.44 of the Revised Code, or to reasonably comply with or to perform in accordance with the terms of a contrac…

(A) If an MCO is affiliated with another individual, corporation, or entity that has had or contemplates activities of any nature with the Ohio workers' compensation system including but not limited to third party administrators, medical or vocational rehabilitation providers, al…

(A) The MCO, in conjunction with the employer, injured worker, attending physician, and the bureau claims personnel assigned to the claim, shall provide medical management and cost containment services that facilitate the provision of high-quality, cost-effective medical care foc…

(A) Upon receipt of notification of a workers' compensation claim, the bureau shall assign a claim number and shall notify the injured worker, employer and MCO of that claim number. The bureau shall determine the compensability of the claim and the allowed conditions of the claim…

(A) The bureau may perform a return-to-work assessment of an injured worker who has eight or more days of lost time due to a work related injury and who has not returned to work within an acceptable timeframe as determined by the bureau.(B) The assessment may include, but is not …

(A) An employer may select any bureau certified MCO that has contracted with the bureau, and has not been placed at capacity pursuant to the MCO contract, during an open enrollment period as provided in this rule. The bureau shall develop a process for verifying an employer's MCO…

(A) An MCO, any individual, corporation, or entity affiliated with the MCO as defined in rule 4123-6-03.9 of the Administrative Code, or any other individual, corporation, or entity acting on behalf of an MCO or for the benefit of an MCO, shall not:(1) Pay, allow, or give, or off…

(A) An MCO shall not solicit, receive, or accept any payment, commission, consideration, money, or other thing of value, including, but not limited to any rebate, premium, or kickback, as an inducement to or in return for the MCO's referral of employers to any sponsoring organiza…

(A) HPP.(1) Except as provided in paragraph (A)(2) of this rule, an injured worker may seek medical care for a work related injury from:(a) A bureau certified provider; or(b) A non-bureau certified provider, subject to an employee's payment responsibilities as delineated in this …

The following services and supplies are never covered by, and shall not be authorized or reimbursed by, the bureau or MCO:(A) Services and supplies that are never covered pursuant to other bureau statutes or rules.(B) The following services and supplies, which are never considere…

(A) Pursuant to division (A)(1)(h) of section 4121.441 of the Revised Code, the administrator of workers' compensation, with the advice and consent of the bureau of workers' compensation board of directors, develops, maintains, and publishes a provider fee schedule for the variou…

(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 clinic…

(A) The bureau shall review all bills received from the MCO pursuant to paragraph (A)(1) of rule 4123-6-10 of the Administrative Code for payment eligibility. The bureau's review may include, but not be limited to, verification of the following:(1) The services were delivered, re…

(A) An MCO shall retain records received from providers and subcontractors that are utilized by the MCO to perform its medical management functions, to substantiate the delivery, value, necessity, and appropriateness of goods and services provided to injured workers, and to devel…

(A) Subject to sections 2317.02, 4123.27, and 4123.88 of the Revised Code, certain employer premium, payroll, and claim file information is confidential and exempt from the general open records laws of Ohio, as set forth in section 149.43 of the Revised Code.(B) In the course of …

(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 regardi…

In reviewing medical treatment reimbursement requests pursuant to rule 4123-6-16.2 of the Administrative Code and conducting independent reviews of medical disputes pursuant to rule 4123-6-16 of the Administrative Code, the MCO and the bureau shall refer to treatment guidelines a…

(A) Medical treatment reimbursement requests (on form C-9 or equivalent) must be submitted by a provider eligible to submit such requests to the MCO responsible for medical management of the claim prior to initiating any non-emergency treatment.The following provider types are el…

(A) Except as otherwise provided in paragraph (D) of this rule, medical treatment reimbursement requests submitted retroactively to the MCO responsible for medical management of claim by a provider eligible to submit such requests, without just cause, for non-emergency treatment …

(A) The administrator of the bureau of workers' compensation may refuse to certify or recertify or may decertify a provider, MCO, or QHP as provided in this chapter.(B) The bureau will monitor and may investigate a provider, MCO, or QHP, and may participate with other state or fe…

(A) Pursuant to division (L) of section 4121.44 of the Revised Code and division (A)(1)(f) of section 4121.441 of the Revised Code, the administrator shall require employees, employers, providers, MCOs, and plans that participate in the workers' compensation system to report data…

(A) The bureau shall take measures and make expenditures, as it deems necessary, to aid injured workers who have sustained compensable injuries or contracted occupational diseases to remain at work.(B) Remain at work services.(1) An injured worker is eligible to receive remain at…

(A) A provider is responsible for the accuracy and legibility of all reports, information, and documentation submitted by the provider, the provider's employees, or the provider's agents to the bureau, industrial commission, injured worker, employer, or their representatives, MCO…

(A) The purpose of this rule is to provide parties to a workers' compensation claim reasonable access to and reasonable charges for medical records necessary for the administration of the claim.(B) Except as provided in this rule, a medical provider shall not assess a fee or char…

(A) Except as otherwise provided in rule 4123-6-21.6 of the Administrative Code, medication must be for the treatment of a work related injury or occupational disease in a claim either allowed by an order of the bureau or the industrial commission. The bureau may deny a drug or t…

(A) Medication must be for treatment of a work related injury or occupational disease in a claim either allowed by an order of the bureau or the industrial commission, or recognized by a self-insuring employer.(B) Any treating provider authorized by law to prescribe medication ma…

The bureau of workers' compensation pharmacy and therapeutics (P&T) committee was created to advise the administrator, the chief of medical services, and the chief medical officer with regard to medication therapy issues for injured workers. The bureau will develop and maintain a…

(A) The administrator hereby adopts the formulary indicated in the appendix to this rule, developed with the recommendation of the bureau's pharmacy and therapeutics committee.(B) Except as otherwise provided in paragraph (F) of this rule, the formulary indicated in the appendix …

The bureau, or a self-insuring employer with a point-of-service adjudication system, may establish a coordinated services program (CSP) that requires an injured worker to obtain prescription medications reimbursed by the bureau or self-insuring employer from a single designated p…

(A) The bureau hereby adopts the standard dose tapering (weaning) schedules for the prescription medications indicated in this rule, and the appendix to this rule.(B) These weaning schedules apply to denials for payment of the indicated medications by the bureau, self-insuring em…

(A) In accordance with division (B) of section 4123.66 of the Revised Code, the administrator has established a program to make immediate payment, under the circumstances set forth in this rule, for the first fill of prescription drugs for medical conditions identified in an appl…

This rule governs the bureau's reimbursement for services to aid injured workers in discontinuing medications which may be necessary and appropriate in the treatment of work related injuries, but which may increase the risk of dependency, misuse, and substance use disorder in som…