Ohio Admin. Code 4123-6-06.2 - Injured worker access to the HPP - injured worker choice of provider
(A) HPP.
(1) Except as provided in paragraph (A)(2) of
this rule, an injured employee
worker may seek medical care for
an industrial
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 paragraph.
(2) Except in cases of emergency,
an injured employee
workers may
not seek medical care for an industrial
injury
work related injuries from
himself, herself
themselves
, or an
immediate family member. An injured
employee
Injured workers may not select
as physician of record, himself,
herself
themselves
, or an immediate family member. The MCO, bureau,
employer, and industrial commission shall not reimburse treatment to
an injured employee
workers
delivered, rendered or directly supervised by the injured
employee
worker or an immediate family member. "Immediate
family member" shall have the same meaning as in paragraph
(A)(3)(b)
(C)(2) of rule 4123-6-02.51 of the Administrative
Code.
(3) At the time of an injury,
the employee
injured worker may seek medical care directly from a
provider or may seek assistance from the MCO in selecting a provider. If the
employee has not already sought medical care or selected a provider, the MCO
may refer the employee to a provider or list of providers. The
employee
injured
worker may, but is not required to, seek medical care from
the referred
that provider or providers. The MCO shall not
discriminate against any category of health care provider when referring the
employee
injured
worker to a provider.
(4) If
the employee
injured worker seeks medical
assistance
care from a provider, the employee
injured
worker shall inform the provider of the employee's
injured
worker's MCO and/or employer. The provider shall then report the
industrial
work
related injury in accordance with rule 4123-6-02.8 of the Administrative
Code.
(a) If the provider is a non-bureau
certified provider, the MCO shall inform the provider that the care for the
first visit will be compensated by the MCO if the claim and the treated
conditions are subsequently allowed and that, unless otherwise permitted by
paragraph (A)(5)(a) or (A)(5)(b) of this rule, no further treatment will be
authorized.
(b) If the provider is
a non-bureau certified provider, the provider shall inform the
employee
injured
worker upon the initial or emergency treatment that the provider is not a
participant in the HPP and that payment will not be made by the bureau, MCO, or
employer for the cost of further treatment after the initial or emergency
treatment
(5) An injured
employee
worker may continue treatment with a non-bureau
certified provider under two circumstances:
(a) The MCO has determined that the treatment
to be provided by the nonbureau certified provider is not reasonably available
through a like bureau certified provider and has authorized the non-bureau
certified provider to continue to provide the treatment, or
(b) The employee
injured
worker may continue to treat with the non-bureau certified provider, but
at the employee's
injured worker's own expense without recourse against
the bureau, MCO, or employer.
(6) Notwithstanding any other provision of
this rule, if the employee's
injured worker's date of injury is prior to
October 20, 1993 and the employee's
injured worker's physician of record is a
non-bureau certified provider, the employee
injured worker may continue treatment
with that non-bureau certified provider. The employer's MCO shall manage the
medical care and treatment and return to work services in the claim and shall
manage medical payment for the provider. However, if the
employee
injured
worker changes the physician of record for any reason, the
employee
injured
worker shall select a bureau certified provider as physician of record.
If the employee
injured worker selects a physician of record who is a
non-bureau certified provider, payment for the provider shall be governed by
the provisions of this rule applicable to non-bureau certified
providers.
(B) QHP.
(1) An employee
injured
worker of an employer that participates in a QHP has freedom of choice of
providers within the QHP network of providers established by the employer's
QHP. If the employee's
injured worker's date of injury is prior to the
establishment of the employer's QHP, and the employee's
injured
worker's physician of record is not a provider on the panel of the QHP
when established, the employee
injured worker may continue treatment with that
physician of record. The physician of record shall be subject to and
participate in the dispute resolution process as provided in rule
4123-6-69
of the Administrative Code. After the establishment of the QHP, the employer's
QHP shall manage the medical care and treatment in the claim. If an injured
worker changes from the physician of record who is not in the QHP for any
reason, the employee
injured worker shall select a QHP panel provider
as the physician of record.
(2) An
employee
injured
worker of an employer that participates in a QHP, who is dissatisfied
with the health care services of a provider in the QHP, after written notice to
the QHP, may request a change of providers and may select another provider
within the QHP, or any bureau certified provider. An employee's
injured
worker's request for change of provider does not require notification to
the bureau, but shall contain the reasons for the request. The QHP shall
approve written requests for a change of provider within the QHP, or to any
bureau certified provider, within seven days of receipt
(3) Notwithstanding the provisions contained
in paragraph (B)(2) of this rule, an employee
injured
worker who incurs a new medical condition, injury or claim requiring
medical treatment, not related to a prior medical condition, injury or claim,
shall first seek treatment from a provider on the panel of the injured worker's
employer's QHP.
(4) Medical
management of all injured workers' claims, whether medical services are
provided within or without the QHP network of providers, shall be provided by
the employer's QHP.
(5) A provider
certified to participate in the HPP shall be eligible to participate in and to
treat injured workers under the QHP system.
(C) Self-insuring employer (non-QHP).
(1) In claims with a date of injury on or
after November 2, 1959, employees
Injured workers of self-insuring employers have free
choice to select licensed physicians for treatment, as well as other medical
services, including, but not limited to, hospital and nursing services. In
claims with a date of injury prior to November 2, 1959, medical services
furnished by the self-insuring employer must be utilized.
(2) Emergency treatment shall not constitute
an exercise of free choice of physician.
(3) Once an employee
injured
worker of a self-insuring employer goes to a physician for treatment
other than on an emergency basis, the employee
injured
worker is deemed to have made a choice of physician and the
employee
injured
worker shall notify the employer of a change of physician.
(a) Change of physician requests shall be
made to the self-insuring employer in writing, and shall include the name and
address of the new physician and the proposed treatment.
(b) Self-insuring employers shall approve
written requests for a change of physician within seven days of
receipt.
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, 4121.44, 4121.441,
Prior Effective Dates: 02/16/1996, 01/01/2001, 02/01/2010, 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) HPP .
(1) Except as provided in paragraph (A)(2) of this rule, an injured employee worker may seek medical care for an industrial 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 paragraph.
(2) Except in cases of emergency , an injured employee workers may not seek medical care for an industrial injury work related injuries from himself, herself themselves , or an immediate family member. An injured employee Injured workers may not select as physician of record, himself, herself themselves , or an immediate family member. The MCO , bureau, employer, and industrial commission shall not reimburse treatment to an injured employee workers delivered, rendered or directly supervised by the injured employee worker or an immediate family member. "Immediate family member" shall have the same meaning as in paragraph (A)(3)(b) (C)(2) of rule 4123-6-02.51 of the Administrative Code.
(3) At the time of an injury , the employee injured worker may seek medical care directly from a provider or may seek assistance from the MCO in selecting a provider . If the employee has not already sought medical care or selected a provider, the MCO may refer the employee to a provider or list of providers. The employee injured worker may, but is not required to, seek medical care from the referred that provider or providers. The MCO shall not discriminate against any category of health care provider when referring the employee injured worker to a provider .
(4) If the employee injured worker seeks medical assistance care from a provider , the employee injured worker shall inform the provider of the employee 's injured worker's MCO and/or employer. The provider shall then report the industrial work related injury in accordance with rule 4123-6-02.8 of the Administrative Code.
(a) If the provider is a non-bureau certified provider , the MCO shall inform the provider that the care for the first visit will be compensated by the MCO if the claim and the treated conditions are subsequently allowed and that, unless otherwise permitted by paragraph (A)(5)(a) or (A)(5)(b) of this rule, no further treatment will be authorized.
(b) If the provider is a non-bureau certified provider , the provider shall inform the employee injured worker upon the initial or emergency treatment that the provider is not a participant in the HPP and that payment will not be made by the bureau, MCO, or employer for the cost of further treatment after the initial or emergency treatment
(5) An injured employee worker may continue treatment with a non-bureau certified provider under two circumstances:
(a) The MCO has determined that the treatment to be provided by the nonbureau certified provider is not reasonably available through a like bureau certified provider and has authorized the non-bureau certified provider to continue to provide the treatment, or
(b) The employee injured worker may continue to treat with the non-bureau certified provider , but at the employee 's injured worker's own expense without recourse against the bureau, MCO , or employer.
(6) Notwithstanding any other provision of this rule, if the employee 's injured worker's date of injury is prior to October 20, 1993 and the employee 's injured worker's physician of record is a non-bureau certified provider , the employee injured worker may continue treatment with that non-bureau certified provider . The employer's MCO shall manage the medical care and treatment and return to work services in the claim and shall manage medical payment for the provider. However, if the employee injured worker changes the physician of record for any reason, the employee injured worker shall select a bureau certified provider as physician of record. If the employee injured worker selects a physician of record who is a non-bureau certified provider , payment for the provider shall be governed by the provisions of this rule applicable to non-bureau certified providers.
(B) QHP .
(1) An employee injured worker of an employer that participates in a QHP has freedom of choice of providers within the QHP network of providers established by the employer's QHP . If the employee 's injured worker's date of injury is prior to the establishment of the employer's QHP, and the employee 's injured worker's physician of record is not a provider on the panel of the QHP when established, the employee injured worker may continue treatment with that physician of record. The physician of record shall be subject to and participate in the dispute resolution process as provided in rule 4123-6-69 of the Administrative Code. After the establishment of the QHP , the employer's QHP shall manage the medical care and treatment in the claim. If an injured worker changes from the physician of record who is not in the QHP for any reason, the employee injured worker shall select a QHP panel provider as the physician of record.
(2) An employee injured worker of an employer that participates in a QHP , who is dissatisfied with the health care services of a provider in the QHP, after written notice to the QHP, may request a change of providers and may select another provider within the QHP, or any bureau certified provider . An employee 's injured worker's request for change of provider does not require notification to the bureau, but shall contain the reasons for the request. The QHP shall approve written requests for a change of provider within the QHP, or to any bureau certified provider , within seven days of receipt
(3) Notwithstanding the provisions contained in paragraph (B)(2) of this rule, an employee injured worker who incurs a new medical condition, injury or claim requiring medical treatment, not related to a prior medical condition, injury or claim, shall first seek treatment from a provider on the panel of the injured worker's employer's QHP.
(4) Medical management of all injured workers' claims, whether medical services are provided within or without the QHP network of providers, shall be provided by the employer's QHP .
(5) A provider certified to participate in the HPP shall be eligible to participate in and to treat injured workers under the QHP system.
(C) Self-insuring employer (non-QHP ).
(1) In claims with a date of injury on or after November 2, 1959, employees Injured workers of self-insuring employers have free choice to select licensed physicians for treatment, as well as other medical services, including, but not limited to, hospital and nursing services. In claims with a date of injury prior to November 2, 1959, medical services furnished by the self-insuring employer must be utilized.
(2) Emergency treatment shall not constitute an exercise of free choice of physician.
(3) Once an employee injured worker of a self-insuring employer goes to a physician for treatment other than on an emergency basis, the employee injured worker is deemed to have made a choice of physician and the employee injured worker shall notify the employer of a change of physician .
(a) Change of physician requests shall be made to the self-insuring employer in writing, and shall include the name and address of the new physician and the proposed treatment.
(b) Self-insuring employers shall approve written requests for a change of physician within seven days of receipt.
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, 4121.44, 4121.441,
Prior Effective Dates: 02/16/1996, 01/01/2001, 02/01/2010, 11/13/2015