Ohio Administrative Code

(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…

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…