Ohio Admin. Code 4123-6-03.2 - MCO participation in the HPP - MCO application for certification or recertification
(A) Upon request by a managed care organization, the bureau shall
send the managed care organization an MCO
an application for certification
for the managed care organization to
which the MCO may complete and submit to the
bureau.
(B) The
MCO application submitted to the bureau by
the managed care organization
MCO shall include a list of bureau certified providers
in its provider panel and/ or bureau certified providers with which the
managed care organization
MCO has arrangements.
(C)
The
MCO
Regardless of whether the MCO elects to
retain a provider panel or enters into provider arrangements, the
application submitted to the bureau by the managed
care organization
MCO shall include the
following, whether the managed care organization
elects to retain a provider panel or enters into provider
arrangements:
(1) A description of
the managed care organization's
MCO's health care provider panel or provider
arrangements, which shall include
including a substantial number of the medical,
health care professional and pharmacy providers currently being utilized by
injured workers. The provider panel or provider arrangements shall cover the
geographic area in which the managed care
organization determines it shall
MCO plans
to compete, and may include out-of-state providers.
(2) A description of how the
managed care organization's
MCO's provider panel or provider arrangements
shall
will
provide timely, geographically convenient access to a full range of medical
services and supplies for injured workers, including access to specialized
services.
(3) A description of the
managed care organization's
MCO's process and methodology for credentialing
providers in the managed care
organization's
MCO's provider panel, if
applicable, and the managed care
organization's
MCO's process and
methodology for assisting non-bureau certified providers in the
managed care organization's
MCO's provider panel or with which the
managed care organization
MCO has provider arrangements in applying for
bureau provider credentialing and certification.
(4) A description of the
managed care organization's
MCO's process and methodology for payment of
providers in the managed care
organization's
MCO's provider panel or
under a provider arrangement.
(5) A
description of the managed care
organization's
MCO's policies and
procedures for sanctioning and terminating providers in the
managed care organization's
MCO's panel, if applicable, and a description of
the managed care organization's
MCO's methodology to notify the bureau, employers
and employees of any changes in the managed care
organization's
MCO's provider panel or
provider arrangements.
(6) A
description of the managed care
organization's
MCO's methodology for
distributing provider panel and provider arrangement directories and directory
updates to employers and employees.
(D) The MCO application for certification submitted to the
bureau by the managed care organization
MCO shall include, at a minimum, the following
information and provisions, as more fully detailed
within the MCO application for certification itself:
(1) A statement that the application is
without misrepresentation, misstatement, or omission of a relevant fact or
other representations involving dishonesty, fraud, or deceit.
(2) A description of the geographic area of
the state of Ohio for which the managed care
organization
MCO wishes to be certified
by the bureau. The minimum geographic area shall
be
is a county. The bureau shall certify
MCO participation on a county basis. The managed
care organization
MCO may apply for
coverage in more than one county or statewide.
(3) A description of the
managed care organization
MCO that includes, but is not limited to, a
profile that includes a disclosure statement regarding the
managed care organization's
MCO's organizational structure, including
subsidiary, parent and affiliate relationships, together with historical and
current data. The managed care organization
MCO must identify its principals; provide the
managed care organization's
MCO's date of incorporation or formation of
partnership, or limited liability company, or business trust; provide any trade
names or fictitious names the managed care
organization
MCO is, or has been, doing
business under; provide the number of years the managed care organization
MCO has operated in Ohio; identify other states in
which the managed care organization
MCO is doing business or has done business;
provide a table of organization with the number of employees; and identify any
banking relationships, including all account information with any financial
institutions.
(4) A description of
the managed care organization's
MCO's business continuation
continuity plan.
(5) A description of the bureau approved
treatment guidelines used by the managed care
organization
MCO , including a description
of how the managed care organization
MCO shall implement the treatment
guidelines.
(6) A description of
the managed care organization's
MCO's utilization review process.
(7) A description of the
managed care organization's
MCO's quality assurance/ improvement standards
program and process, including the use of satisfaction surveys.
(8) A description of the
managed care organization's
MCO's medical dispute resolution process that
meets the requirements of rule
4123-6-16
of the Administrative Code.
(9) A
description of the managed care
organization's
MCO's administrative and
bill payment grievance processes.
(10) A description of the
managed care organization's
MCO's information system platforms, capabilities
and capacities; a description of the managed care
organization's
MCO's system for
reporting necessary data elements, including but not limited to those required
for performance measurements; and the managed care
organization's
MCO's measures in place
to ensure data security, including back-up systems.
(11) A description of the
managed care organization's
MCO's medical case management policies and
procedures.
(12) A description of
the managed care organization's
MCO's policies and procedures regarding the
protection of confidential and sensitive records.
(13) A description of the
managed care organization's
MCO's policies and procedures regarding retention
of information.
(14) A description
of the managed care organization's
MCO's provider relations and education
program.
(15) A description of the
managed care organization's
MCO's employer and employee relations and
education program, including but not limited to a description of methodologies
to be used to explain options available to injured workers, including treatment
by non-network providers and the dispute resolution process.
(16) A description of the
managed care organization's
MCO's provider bill payment processes including,
but not limited to, clinical editing software (including review criteria,
process and methodology).
(17)
Attestation of intent to obtain and maintain insurance coverage as required by
the MCO contract, with proof of such coverage to be submitted to the bureau
prior to execution of the contract, and current workers' compensation
coverage.
(18) Attestation of
intent to obtain and maintain professional accreditations as required by the
MCO contract, with proof of such accreditations to be submitted to the bureau
prior to execution of the contract.
(19) A description of any and all individuals
and entities the managed care organization
MCO is affiliated with (including, but not
limited to, a subcontractor or subcontractee, vendor or vendee, joint venture
or other arrangement), and a copy of the MCO's contract or agreement with each
individual or entity. For purposes of this rule, "affiliated with the MCO"
shall have the same meaning as defined in paragraph (B) of rule 4123-6-03.9 of
the Administrative Code.
(20) Other
descriptions and requirements as contained in divisions (F)(1) to (F)(10) of
section
4121.44
of the Revised Code.
(E)
For MCO recertification, prior to the expiration of an MCO's certification, the
bureau shall send the certified MCO an application for recertification, which
must be completed and returned to the bureau. The MCO must be able to provide
proof of delivery of the completed application to the bureau upon request. The
MCO application for recertification may be
amended from time to time at the bureau's discretion.
(F) The bureau shall review the application
for certification or recertification submitted by the
managed care organization
MCO . The bureau reserves the right to cross-check data
with other governmental agencies or licensing or accrediting bodies.
(G) During the bureau's review of the
application for certification or recertification, the
managed care organization
MCO shall provide to the bureau any additional
documentation requested and shall permit the bureau, upon request and with
reasonable notice given, to conduct an onsite review of the
managed care organization
MCO .
(H)
A managed care organization
an MCO may cure any defects in its application
for certification or recertification within thirty days of notice by the bureau
of such defect in its application.
(I) The bureau may require that the
application be accompanied by an application fee, which shall not exceed the
amount sufficient to cover the cost of processing the application.
(J) The bureau shall hold as confidential and
proprietary information contained in a managed care
organization's
an MCO's application for
certification or recertification, and other information furnished to the bureau
by A managed care organization
an MCO for purposes of obtaining certification or
to comply with performance and auditing requirements established by the
administrator, in accordance with divisions (H)(1) and (H)(2) of section
4121.44
of the Revised Code.
(K) The bureau
shall not accept or approve any MCO
application for certification or recertification in which the
managed care organization
MCO proposes to subcontract or outsource medical
case management services, other than as part of the
MCO's business continuity plan as described in paragraph (D)(4) of this rule
and approved by the bureau . However, an MCO may subcontract onsite or
out-of-state medical case management services with the prior approval of the
bureau, provided such services are conducted under the supervision of the
MCO.
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Rule Amplifies: 4121.12, 4121.121, 41, 4121.44, 4121.441
Prior Effective Dates: 02/16/1996, 01/01/1999, 01/01/2001, 02/14/2005, 02/01/2010, 07/16/2012, 06/09/2014, 11/13/2015
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(A) Upon request by a managed care organization , the bureau shall send the managed care organization an MCO an application for certification for the managed care organization to which the MCO may complete and submit to the bureau.
(B) The MCO application submitted to the bureau by the managed care organization MCO shall include a list of bureau certified providers in its provider panel and/ or bureau certified providers with which the managed care organization MCO has arrangements.
(C) The MCO Regardless of whether the MCO elects to retain a provider panel or enters into provider arrangements, the application submitted to the bureau by the managed care organization MCO shall include the following, whether the managed care organization elects to retain a provider panel or enters into provider arrangements:
(1) A description of the managed care organization 's MCO 's health care provider panel or provider arrangements, which shall include including a substantial number of the medical, health care professional and pharmacy providers currently being utilized by injured workers. The provider panel or provider arrangements shall cover the geographic area in which the managed care organization determines it shall MCO plans to compete, and may include out-of-state providers.
(2) A description of how the managed care organization 's MCO 's provider panel or provider arrangements shall will provide timely, geographically convenient access to a full range of medical services and supplies for injured workers, including access to specialized services.
(3) A description of the managed care organization 's MCO 's process and methodology for credentialing providers in the managed care organization 's MCO 's provider panel, if applicable, and the managed care organization 's MCO 's process and methodology for assisting non-bureau certified providers in the managed care organization 's MCO 's provider panel or with which the managed care organization MCO has provider arrangements in applying for bureau provider credentialing and certification .
(4) A description of the managed care organization 's MCO 's process and methodology for payment of providers in the managed care organization 's MCO 's provider panel or under a provider arrangement.
(5) A description of the managed care organization 's MCO 's policies and procedures for sanctioning and terminating providers in the managed care organization 's MCO 's panel, if applicable, and a description of the managed care organization 's MCO 's methodology to notify the bureau, employers and employees of any changes in the managed care organization 's MCO 's provider panel or provider arrangements.
(6) A description of the managed care organization 's MCO 's methodology for distributing provider panel and provider arrangement directories and directory updates to employers and employees.
(D) The MCO application for certification submitted to the bureau by the managed care organization MCO shall include, at a minimum, the following information and provisions, as more fully detailed within the MCO application for certification itself:
(1) A statement that the application is without misrepresentation, misstatement, or omission of a relevant fact or other representations involving dishonesty, fraud, or deceit.
(2) A description of the geographic area of the state of Ohio for which the managed care organization MCO wishes to be certified by the bureau. The minimum geographic area shall be is a county. The bureau shall certify MCO participation on a county basis. The managed care organization MCO may apply for coverage in more than one county or statewide.
(3) A description of the managed care organization MCO that includes, but is not limited to, a profile that includes a disclosure statement regarding the managed care organization 's MCO 's organizational structure, including subsidiary, parent and affiliate relationships, together with historical and current data. The managed care organization MCO must identify its principals; provide the managed care organization 's MCO 's date of incorporation or formation of partnership, or limited liability company, or business trust; provide any trade names or fictitious names the managed care organization MCO is, or has been, doing business under; provide the number of years the managed care organization MCO has operated in Ohio; identify other states in which the managed care organization MCO is doing business or has done business; provide a table of organization with the number of employees; and identify any banking relationships, including all account information with any financial institutions.
(4) A description of the managed care organization 's MCO 's business continuation continuity plan.
(5) A description of the bureau approved treatment guidelines used by the managed care organization MCO , including a description of how the managed care organization MCO shall implement the treatment guidelines .
(6) A description of the managed care organization 's MCO 's utilization review process.
(7) A description of the managed care organization 's MCO 's quality assurance/ improvement standards program and process, including the use of satisfaction surveys.
(8) A description of the managed care organization 's MCO 's medical dispute resolution process that meets the requirements of rule 4123-6-16 of the Administrative Code.
(9) A description of the managed care organization 's MCO 's administrative and bill payment grievance processes.
(10) A description of the managed care organization 's MCO 's information system platforms, capabilities and capacities; a description of the managed care organization 's MCO 's system for reporting necessary data elements, including but not limited to those required for performance measurements; and the managed care organization 's MCO 's measures in place to ensure data security, including back-up systems.
(11) A description of the managed care organization 's MCO 's medical case management policies and procedures.
(12) A description of the managed care organization 's MCO 's policies and procedures regarding the protection of confidential and sensitive records.
(13) A description of the managed care organization 's MCO 's policies and procedures regarding retention of information.
(14) A description of the managed care organization 's MCO 's provider relations and education program.
(15) A description of the managed care organization 's MCO 's employer and employee relations and education program, including but not limited to a description of methodologies to be used to explain options available to injured workers, including treatment by non-network providers and the dispute resolution process.
(16) A description of the managed care organization 's MCO 's provider bill payment processes including, but not limited to, clinical editing software (including review criteria, process and methodology).
(17) Attestation of intent to obtain and maintain insurance coverage as required by the MCO contract, with proof of such coverage to be submitted to the bureau prior to execution of the contract, and current workers' compensation coverage.
(18) Attestation of intent to obtain and maintain professional accreditations as required by the MCO contract, with proof of such accreditations to be submitted to the bureau prior to execution of the contract.
(19) A description of any and all individuals and entities the managed care organization MCO is affiliated with (including, but not limited to, a subcontractor or subcontractee, vendor or vendee, joint venture or other arrangement), and a copy of the MCO 's contract or agreement with each individual or entity. For purposes of this rule, "affiliated with the MCO " shall have the same meaning as defined in paragraph (B) of rule 4123-6-03.9 of the Administrative Code.
(20) Other descriptions and requirements as contained in divisions (F)(1) to (F)(10) of section 4121.44 of the Revised Code.
(E) For MCO recertification , prior to the expiration of an MCO's certification , the bureau shall send the certified MCO an application for recertification, which must be completed and returned to the bureau. The MCO must be able to provide proof of delivery of the completed application to the bureau upon request. The MCO application for recertification may be amended from time to time at the bureau's discretion.
(F) The bureau shall review the application for certification or recertification submitted by the managed care organization MCO . The bureau reserves the right to cross-check data with other governmental agencies or licensing or accrediting bodies.
(G) During the bureau's review of the application for certification or recertification, the managed care organization MCO shall provide to the bureau any additional documentation requested and shall permit the bureau, upon request and with reasonable notice given, to conduct an onsite review of the managed care organization MCO .
(H) A managed care organization an MCO may cure any defects in its application for certification or recertification within thirty days of notice by the bureau of such defect in its application.
(I) The bureau may require that the application be accompanied by an application fee, which shall not exceed the amount sufficient to cover the cost of processing the application.
(J) The bureau shall hold as confidential and proprietary information contained in a managed care organization 's an MCO 's application for certification or recertification, and other information furnished to the bureau by A managed care organization an MCO for purposes of obtaining certification or to comply with performance and auditing requirements established by the administrator, in accordance with divisions (H)(1) and (H)(2) of section 4121.44 of the Revised Code.
(K) The bureau shall not accept or approve any MCO application for certification or recertification in which the managed care organization MCO proposes to subcontract or outsource medical case management services, other than as part of the MCO 's business continuity plan as described in paragraph (D)(4) of this rule and approved by the bureau . However, an MCO may subcontract onsite or out-of-state medical case management services with the prior approval of the bureau, provided such services are conducted under the supervision of the MCO .
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Rule Amplifies: 4121.12, 4121.121, 41, 4121.44, 4121.441
Prior Effective Dates: 02/16/1996, 01/01/1999, 01/01/2001, 02/14/2005, 02/01/2010, 07/16/2012, 06/09/2014, 11/13/2015