Chapter 4123-6 | Health Partnership Program

The bureau of workers' compensation stakeholders' health care quality assurance advisory committee (HCQAAC) was created to advise the administrator, the chief of medical services, and the chief medical officer with regard to medical quality issues. A list of medical providers, ea…

(A) Medical or other services to be approved for payment must be rendered as a result of an injury sustained or occupational disease contracted by an injured worker in the course of and arising out of employment. The claim must be allowed by an order of either the bureau of worke…

(A) When the claimant or any other person making payment on behalf of the claimant, including a volunteer, pays for medical services or supplies directly to a health care provider and the medical services or supplies meet the criteria in paragraph (B) of rule 4123-6-16.2 of the A…

h 119. PDF: Medical fees shall not be approved for treatment by more than one physician for the same condition over the same period of time, except where a consultant, anesthetist, or assistant is required, or where the necessity for treatment by a specialist is clearly shown and…

A provider treating an injured worker may, at any time, make a request in writing, facsimile, or e-mail, in accordance with the bureau's confidentiality and sensitive data requirements, for relevant information concerning conditions, treatment or history for the claim. The reques…

(A) "Physical medicine" is the evaluation and treatment of an injured worker by physical measures and the use of rehabilitative procedures, with or without assistive devices, for the purpose of preventing, correcting, or alleviating any work related disability. Physical medicine …

(A) Acupuncture.Acupuncture is eligible for reimbursement when prior authorized and administered by a licensed doctor of medicine, doctor of osteopathic medicine and surgery, or doctor of podiatric medicine, a doctor of chiropractic who holds a certificate to practice acupuncture…

This rule governs the identification and medical management of claims necessitating supportive care, including medical treatment reimbursement authorization. The objective is to ensure the timely and efficient provision of medically necessary and appropriate treatment reasonably …

Reimbursement for lumbar fusion surgery for treatment of allowed conditions in a claim resulting from an allowed industrial injury or occupational disease shall be limited to claims in which current best medical practices as implemented by this rule are followed.This rule governs…

This rule governs the bureau's reimbursement for health behavior assessment and intervention (HBAI) services offered to injured workers who may benefit from an assessment that focuses on identifying behavioral barriers impeding the injured worker's recovery which may be addressed…

This rule governs the bureau's reimbursement for services in an allowed claim related to concussion. It is not meant to preclude, or substitute for, the health care provider's responsibility to exercise sound clinical judgment in light of current best medical practices when treat…

Reimbursement for a spinal cord stimulator for treatment of allowed conditions in a claim resulting from an allowed work related injury or occupational disease is limited to claims in which current best medical practices as implemented by this rule are followed.This rule governs …

This rule governs the bureau's enhanced care program for injured workers who have sustained a compensable knee injury. The program is designed to simplify the claims management process and encourage higher quality, better coordinated care for eligible claims that results in impro…

(A) Direct reimbursement will not be made to members of a hospital resident staff.(B) Payment for personal comfort items, which include, but are not limited to, telephones, television, and private rooms provided at the patient's request, are not compensable.(C) Bureau fees for ho…

(A) HPP. Except as provided in paragraphs (A)(7) and (A)(8) of this rule, reimbursement for hospital inpatient services with a discharge date of February 1, 2026 or after will be calculated as follows:(1) (a) Reimbursement for hospital inpatient services, other than outliers as d…

(A) HPP:Unless an MCO has negotiated a different payment rate with a hospital pursuant to rule 4123-6-10 of the Administrative Code, reimbursement for hospital outpatient services with a date of service of May 1, 2026 or after will be the applicable rate set forth in this rule as…

Unless an MCO has negotiated a different payment rate with an ambulatory surgical center pursuant to rule 4123-6-10 of the Administrative Code, reimbursement for ambulatory surgical center services with a date of service of May 1, 2026 or after will be equal to the lesser of the …

(A) Except as provided in rule 4123-6-38.1 of the Administrative Code, home health nursing services and home health aide services shall be provided by registered nurses or licensed practical nurses and home health aides employed by a home health agency meeting the qualifications …

(A) Nursing services provided prior to December 14, 1992.(1) Registered nurses and licensed practical nurses who are not employed by a home health agency a home health agency certified in accordance with rule 4123-6-02.2 of the Administrative Code may continue to provide authoriz…

(A) Payment to a nursing home or residential care/assisted living facility for the care of an injured worker who sustained an injury or contracted an occupational disease in the course of and arising out of employment shall be made only when the need for such care is the direct r…

(A) For purposes of this rule:(1) "Amputee clinic" means an interdisciplinary group of professional providers led by a physician with a specialty in physical medicine and rehabilitation, orthopedic surgery, vascular surgery, or other applicable speciality knowledgeable in the fie…

(A) An injured worker's reasonable and necessary travel expenses shall be paid, upon the filing of a proper request, under the following circumstances:(1) When the injured worker has been ordered or authorized to undergo a medical examination outside of the city or community limi…

(A) Direct payment to a health care provider or other person by the industrial commission, self-insuring employer, bureau of workers' compensation, or their agent, for medical care rendered to an injured worker does not imply or create a legal relationship between the provider or…

(A) Payment is made for equipment, materials, goods, supplies, or services incurred by the claimant in connection with claims against the state insurance fund, public work relief employees' compensation fund, coal workers pneumoconiosis fund, or marine industry fund in accordance…

(A) Payment will be approved for a transcutaneous electric nerve stimulator (TENS) unit for treatment of allowed conditions in a claim resulting from an allowed work related injury or occupational disease, as provided in this rule.(1) Prior authorization is required for TENS unit…

Bureau fees for in-state or out-of-state providers will be established by the bureau. The bureau may establish different fees for in-state and out-of-state providers. The methods of payment may include rates based on resource based relative value scale (RBRVS), per cent of allowe…

(A) Providers' patient and billing related records, including but not limited to those records described in rule 4123-6-45.1 of the Administrative Code, may be reviewed by the bureau or the MCO to ensure workers are receiving proper and necessary medical care, and to ensure compl…

(A) A health care provider shall create, maintain, and retain sufficient records, papers, books, and documents in such form to fully substantiate the delivery, value, necessity, and appropriateness of goods and services provided to injured workers under the HPP or of significant …

(A) The bureau or self-insuring employer may negotiate payment rates with health care providers for services and supplies provided in the treatment of workers' compensation claims.(B) The bureau or self-insuring employer may enter into volume-based or optional-use contracts with …

(A) A health plan that satisfies the QHP certification requirements of this chapter shall be certified by the bureau as a QHP to manage medical treatment, direct care or provide services or supplies to or on behalf of an employee for an injury or occupational disease that is comp…

(A) The bureau shall initiate the recertification process by sending certified QHPs a recertification application, which must be completed, signed, and submitted to the bureau if the QHP wishes to be considered for recertification.(B) Except as otherwise provided in paragraph (E)…

(A) Each QHP shall have a quality assurance program that monitors the operation and measures the effectiveness of peer review, utilization review, and dispute resolution within the QHP. Data collected from the quality assurance program shall be used to assist an employer in deter…

(A) Upon request by an employer or health plan seeking certification, the bureau shall mail the employer or health plan seeking certification a QHP application for certification.(B) The QHP application for certification shall include a list of bureau certified providers in the QH…

(A) The bureau may refuse to certify or recertify or may decertify a QHP from participation in the QHP system.(B) Should the bureau determine that sufficient evidence exists that an employer or QHP has failed to comply with applicable workers' compensation statutes or rules gover…

A QHP or vendor that provides medical management and cost containment services shall not require a provider to participate in a workers' compensation network of providers in order to maintain membership in a related health care program. If the QHP utilizes a leased provider netwo…

(A) An employer that develops a QHP, a vendor within the QHP system, or a QHP shall develop and implement standards of credentialing of providers in the QHP network that meet but may exceed the bureau credentialing requirements in the HPP.(B) An employer that develops a QHP may s…

h 119. PDF: The bureau shall not interfere with nor impose restrictions upon an arrangement for payment negotiated between an employer and a vendor that provides medical management and cost containment services and/or a QHP under the QHP system, except that no financial arrangeme…

(A) This rule shall provide time frames and procedures for review of requests for the delivery of medical services and for the resolution of disputes that may arise between an employee and an employer, an employee and a provider, or an employer and a provider. This rule applies t…

(A) To enhance the quality of the QHP system and pursuant to division (L)(1) of section 4121.44 of the Revised Code, the administrator shall require employers and QHPs that participate in the workers' compensation QHP system to report data to be used by the administrator to measu…

Subject to the requirements and protections contained in Ohio law pertaining to release of confidential or privileged information in the course of medical management in the QHP system, confidential information may be exchanged among the bureau, the QHPs, an employer and its repre…