Ohio Admin. Code 4123-6-16 - Alternative dispute resolution for HPP medical issues
(A) Pursuant to
division (A)(1) of section
4121.441
of the Revised Code, this rule shall provide procedures for an alternative
dispute resolution (ADR) process for medical disputes between an employer, an
employee
injured
worker , or a provider and an MCO arising from the MCO's decision
regarding a medical treatment reimbursement request (on form C-9 or
equivalent). An employee
injured worker or employer must exhaust the ADR
procedures of this rule prior to filing an appeal under section
4123.511
of the Revised Code on an MCO's decision regarding a medical treatment
reimbursement request.
(B) Within
fourteen days of receipt of an MCO decision, an employee
injured
worker , employer, or provider may dispute the decision in writing (on
form C-11 or equivalent) to the MCO. The written medical dispute must contain,
at a minimum, the following elements:
(1)
Injured worker name.
(2) Injured
worker claim number.
(3) Date of
initial medical treatment reimbursement request in dispute.
(4) Specific issue(s) in dispute, including
description, frequency/duration, beginning/ending dates, and type of
treatment/service/body part.
(5)
Name of party making written appeal request.
(6) Signature of party making written appeal
request or the party's authorized representative.
Written medical disputes that do not contain the minimum elements set forth in this paragraph may be dismissed by the MCO or bureau.
(C) Upon
receipt of a written medical dispute, the MCO shall initiate the ADR process.
The MCO's ADR process shall consist of one independent level of professional
review as follows:
(1) If an individual
health care provider eligible to be physician of record would be providing the
services requested in the dispute, the independent level of professional review
shall consist of a peer review conducted by an individual or individuals
licensed pursuant to the same section of the Revised Code as the health care
provider who would be providing the services requested.
(2) Notwithstanding paragraph (C)(1) of this
rule, if the MCO has already obtained one or more peer reviews during previous
disputes involving the same or similar treatment, the MCO may obtain a
different perspective review from a licensed physician who falls outside the
peer review criteria set forth above.
(3) If an individual health care provider not
eligible to be physician of record would be providing the services requested in
the dispute, the independent level of professional review shall consist of a
provider review conducted by an individual or individuals eligible to be
physician of record whose scope of practice includes the services
requested.
(4) If the MCO receives
a dispute where the requested treatment appears to be the same as or similar to
a previous treatment request for which the MCO conducted a professional review,
and the previous treatment request was ultimately denied based on the
professional review, the MCO may use the previous professional review to
satisfy the independent level of professional review requirement of this
paragraph.
(5) The MCO shall submit
a copy of the professional review to the bureau, and the bureau shall provide
the parties to the claim access to the professional review
electronically.
(D) If,
upon consideration of additional evidence or after agreement with the party
that submitted the written medical dispute, the MCO reverses the decision under
dispute or otherwise resolves the dispute to the satisfaction of the party, the
MCO may issue a new decision and dismiss the dispute.
(E) Unless the MCO reverses the decision
under dispute pursuant to paragraph (D) of this rule, the MCO shall complete
the ADR process and submit its recommended ADR decision to the bureau
electronically within twenty-one days of the MCO's receipt of the written
medical dispute. The MCO may recommend that the employee be scheduled for an
independent medical examination. This recommendation shall toll the MCO's time
frame for completing the ADR process, and in such cases the MCO shall submit
its recommended ADR decision to the bureau electronically within seven days
after receipt of the independent medical examination report.
(F) Within two business days after receipt of
a recommended ADR decision from the MCO, the bureau shall publish a final
order. This order shall be mailed to all parties and may be appealed to the
industrial commission pursuant to section
4123.511
of the Revised Code. The provider and the MCO may not file an appeal of the
bureau order.
(G) Notwithstanding
paragraph (C) of this rule, the MCO may pend a written medical dispute under
the following circumstances:
(1) If the MCO
receives a written medical dispute involving a medical treatment reimbursement
request that appears to be the same as or similar to a previous treatment
request for which the MCO conducted a provider review, and the previous
treatment request is pending before the bureau or industrial commission, the
MCO may pend the new dispute until the previous treatment request has been
resolved. Once the previous treatment request has been resolved, the MCO shall
resume the ADR process, and may proceed in accordance with paragraph (C)(4) of
this rule if appropriate.
(2) If
the MCO receives a written medical dispute involving a medical treatment
reimbursement request relating to the delivery of medical services for a
condition that is not allowed in the claim, and the issue of the allowance of
the additional condition is pending before the bureau or industrial commission,
the MCO may pend the dispute until the earlier of the final administrative or
judicial decision or the industrial commission staff hearing officer decision
on the allowance of the additional condition, at which time the MCO shall
resume the ADR process.
(H) Notwithstanding paragraph (C) of this
rule, an MCO may submit its recommended ADR decision to the bureau
electronically without obtaining an independent level of professional review
under the following circumstances:
(1) The
MCO receives a written medical dispute involving a medical treatment
reimbursement request relating to the delivery of medical services that have
been approved by the MCO pursuant to standard treatment guidelines, pathways,
or presumptive authorization guidelines.
(2) The MCO receives a written medical
dispute involving a medical treatment reimbursement request relating to the
delivery of medical services for a condition that is not allowed in the claim,
and the issue of the allowance of the additional condition is not pending
before the bureau or industrial commission.
(I)
Either the MCO or
the bureau may schedule an independent medical examination (IME) of the
claimant to assist in the ADR process under this rule.
(1)
An ADR IME will
be limited to issues relating to medical treatment disputes, and will not
include extent of disability issues. An ADR IME will not be conducted at the
request of an employer and does not substitute for an examination permitted
under section
4123.651
of the Revised Code.
(2)
If an ADR IME is scheduled under this rule, the
parties, and their representatives, if any, will be promptly notified as to the
time and place of the examination, and the questions and information provided
to the doctor. An electronic copy of the ADR IME report will be submitted to
the claim file. The injured worker will be reimbursed for travel expenses in
accordance with rule
4123-6-40
of the Administrative Code.
(3)
If an injured
worker refuses to attend an IME to assist in the ADR process, the MCO will
refer the issue to the bureau, and the injured worker's right to benefits may
be suspended during the period of refusal.
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, 06/06/1997, 01/01/1999, 11/08/1999, 01/01/2001, 01/01/2003, 04/01/2007, 09/25/2008, 11/01/2009, 11/13/2015
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(A) Pursuant to division (A)(1) of section 4121.441 of the Revised Code, this rule shall provide procedures for an alternative dispute resolution (ADR) process for medical disputes between an employer, an employee injured worker , or a provider and an MCO arising from the MCO's decision regarding a medical treatment reimbursement request (on form C-9 or equivalent). An employee injured worker or employer must exhaust the ADR procedures of this rule prior to filing an appeal under section 4123.511 of the Revised Code on an MCO 's decision regarding a medical treatment reimbursement request.
(B) Within fourteen days of receipt of an MCO decision, an employee injured worker , employer, or provider may dispute the decision in writing (on form C-11 or equivalent) to the MCO. The written medical dispute must contain, at a minimum, the following elements:
(1) Injured worker name.
(2) Injured worker claim number.
(3) Date of initial medical treatment reimbursement request in dispute.
(4) Specific issue(s) in dispute, including description, frequency/duration, beginning/ending dates, and type of treatment/service/body part.
(5) Name of party making written appeal request.
(6) Signature of party making written appeal request or the party's authorized representative.
Written medical disputes that do not contain the minimum elements set forth in this paragraph may be dismissed by the
(C) Upon receipt of a written medical dispute, the MCO shall initiate the ADR process. The MCO 's ADR process shall consist of one independent level of professional review as follows:
(1) If an individual health care provider eligible to be physician of record would be providing the services requested in the dispute, the independent level of professional review shall consist of a peer review conducted by an individual or individuals licensed pursuant to the same section of the Revised Code as the health care provider who would be providing the services requested.
(2) Notwithstanding paragraph (C)(1) of this rule, if the MCO has already obtained one or more peer reviews during previous disputes involving the same or similar treatment, the MCO may obtain a different perspective review from a licensed physician who falls outside the peer review criteria set forth above.
(3) If an individual health care provider not eligible to be physician of record would be providing the services requested in the dispute, the independent level of professional review shall consist of a provider review conducted by an individual or individuals eligible to be physician of record whose scope of practice includes the services requested.
(4) If the MCO receives a dispute where the requested treatment appears to be the same as or similar to a previous treatment request for which the MCO conducted a professional review, and the previous treatment request was ultimately denied based on the professional review, the MCO may use the previous professional review to satisfy the independent level of professional review requirement of this paragraph.
(5) The MCO shall submit a copy of the professional review to the bureau, and the bureau shall provide the parties to the claim access to the professional review electronically.
(D) If, upon consideration of additional evidence or after agreement with the party that submitted the written medical dispute, the MCO reverses the decision under dispute or otherwise resolves the dispute to the satisfaction of the party, the MCO may issue a new decision and dismiss the dispute.
(E) Unless the MCO reverses the decision under dispute pursuant to paragraph (D) of this rule, the MCO shall complete the ADR process and submit its recommended ADR decision to the bureau electronically within twenty-one days of the MCO 's receipt of the written medical dispute. The MCO may recommend that the employee be scheduled for an independent medical examination. This recommendation shall toll the MCO's time frame for completing the ADR process, and in such cases the MCO shall submit its recommended ADR decision to the bureau electronically within seven days after receipt of the independent medical examination report.
(F) Within two business days after receipt of a recommended ADR decision from the MCO , the bureau shall publish a final order. This order shall be mailed to all parties and may be appealed to the industrial commission pursuant to section 4123.511 of the Revised Code. The provider and the MCO may not file an appeal of the bureau order.
(G) Notwithstanding paragraph (C) of this rule, the MCO may pend a written medical dispute under the following circumstances:
(1) If the MCO receives a written medical dispute involving a medical treatment reimbursement request that appears to be the same as or similar to a previous treatment request for which the MCO conducted a provider review, and the previous treatment request is pending before the bureau or industrial commission, the MCO may pend the new dispute until the previous treatment request has been resolved. Once the previous treatment request has been resolved, the MCO shall resume the ADR process, and may proceed in accordance with paragraph (C)(4) of this rule if appropriate.
(2) If the MCO receives a written medical dispute involving a medical treatment reimbursement request relating to the delivery of medical services for a condition that is not allowed in the claim, and the issue of the allowance of the additional condition is pending before the bureau or industrial commission, the MCO may pend the dispute until the earlier of the final administrative or judicial decision or the industrial commission staff hearing officer decision on the allowance of the additional condition, at which time the MCO shall resume the ADR process.
(H) Notwithstanding paragraph (C) of this rule, an MCO may submit its recommended ADR decision to the bureau electronically without obtaining an independent level of professional review under the following circumstances:
(1) The MCO receives a written medical dispute involving a medical treatment reimbursement request relating to the delivery of medical services that have been approved by the MCO pursuant to standard treatment guidelines, pathways, or presumptive authorization guidelines.
(2) The MCO receives a written medical dispute involving a medical treatment reimbursement request relating to the delivery of medical services for a condition that is not allowed in the claim, and the issue of the allowance of the additional condition is not pending before the bureau or industrial commission.
(I) Either the MCO or the bureau may schedule an independent medical examination (IME) of the claimant to assist in the ADR process under this rule.
(1) An ADR IME will be limited to issues relating to medical treatment disputes, and will not include extent of disability issues. An ADR IME will not be conducted at the request of an employer and does not substitute for an examination permitted under section 4123.651 of the Revised Code.
(2) If an ADR IME is scheduled under this rule, the parties, and their representatives, if any, will be promptly notified as to the time and place of the examination, and the questions and information provided to the doctor. An electronic copy of the ADR IME report will be submitted to the claim file. The injured worker will be reimbursed for travel expenses in accordance with rule 4123-6-40 of the Administrative Code.
(3) If an injured worker refuses to attend an IME to assist in the ADR process, the MCO will refer the issue to the bureau, and the injured worker's right to benefits may be suspended during the period of refusal.
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, 06/06/1997, 01/01/1999, 11/08/1999, 01/01/2001, 01/01/2003, 04/01/2007, 09/25/2008, 11/01/2009, 11/13/2015