Ohio Administrative Code

(A) Except as otherwise provided in this rule, fee bills for medical or vocational rehabilitation services rendered in a claim shall be submitted to the bureau or commission for payment within one year of the date on which the service was rendered or one year after the date the s…

When a controversy exists between a party and the party's representative concerning fees for services rendered in industrial claims, either the party or the representative may make a written request to the industrial commission to resolve the dispute, the matter being within the …

(A) Eligibility for a change of occupation allowance.(1) Where it is found that a change of occupation is medically advisable for an employee suffering from silicosis, coal miners' pneumoconiosis, or asbestosis contracted in the course of employment, but the employee is not total…

(A) Whether a claimant is or is not represented in an industrial claim is a matter of the claimant's free choice. No employee of the bureau or of a self-insuring employer shall directly or indirectly convey any information in derogation of this right.(B) Upon receipt of a claim, …

(A) On and after August 22, 1986, all persons, without regard to date of injury, who are receiving compensation for permanent and total disability which, when combined with disability benefits received pursuant to the Social Security Act, is less than three hundred forty-two doll…

(A) Pursuant to section 4123.53 of the Revised Code, the bureau of workers' compensation shall schedule an examination, for a date not later than thirty days following the end of the initial ninety-day period of temporary total disability compensation, to determine the employee's…

(A) The procedures of this rule shall apply to the settlement of state fund injury and occupational disease claims.(B) The employer or the claimant shall file an application for approval of settlement agreement on the appropriate form with the administrator of workers' compensati…

(A) For the purposes of disability relief under section 4123.343 of the Revised Code, an "employee with a disability" means an employee who is defined as having one or more of the conditions listed in division (A) of section 4123.343 of the Revised Code.(1) With respect to the co…

(A) In accordance with division (A) of section 4123.511 of the Revised Code the administrator has established a program to immediately allow specific medical conditions which have a historical record of being allowed whenever included in a claim and having low medical costs.The m…

(A) The administrator of the bureau of workers' compensation, under special circumstances, may commute an award of compensation to a lump sum payment when the administrator determines the advancement is advisable for the purpose of providing the claimant or the surviving spouse f…

(A) Pursuant to section 4123.932 of the Revised Code and when an employer satisfies all of the requirements of this rule, the bureau shall charge to the surplus fund created under division (B) of section 4123.34 of the Revised Code any compensation and benefits related to a compe…

The administrator of workers' compensation may reorganize the work of the bureau of workers' compensation to the extent necessary to achieve the most efficient performance of its functions. The duties of the operational units of the bureau include, but are not limited to the foll…

The bureau of workers' compensation will not accept an employer's report on application for payment of compensation and/or benefits, payroll reports, settlement sheets, and other instruments which employers are required to submit to the bureau unless the document is signed by an …

(A) The date of death governs the amount of funeral benefits to be paid in a death claim for the funeral expenses of an employee who has died as a result of an allowed work-related industrial injury or occupational disease. In such cases no disbursements shall be made in excess o…

(A) Except as provided in paragraph (E) of this rule and paragraph (B)(1)(b) of rule 4123-3-09 of the Administrative Code, no payment of compensation shall be approved by the bureau of workers' compensation in a claim unless supported by a report of a physician duly licensed to r…

(A) Except for payments made to claimants under a contract of hire or under a collective bargaining agreement by an employer that is a professional sports franchise domiciled in Ohio, whenever a claimant and the employer advise the bureau of workers' compensation in writing that …

(A) When a claimant dies, action on any application filed by the claimant, and pending before the bureau of workers' compensation or the industrial commission at the time of their death, is abated by claimant's death.(B) Abatement of action, as described in paragraph (A) of this …

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…