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
improved outcomes.
(A)
Notwithstanding any provision to the contrary in any
other rule of the bureau, the administrator may, for purposes of the enhanced
care program, allow one or more managed care organizations to authorize medical
treatment reimbursement requests for the first sixty days from the initial
allowance of an eligible claim for any conditions within the same knee as the
conditions initially allowed in the claim, and presumed to be causally related
to the same industrial injury or occupational disease, without disclaimer,
during such time as the conditions for which treatment reimbursement is
authorized but which are not yet allowed are being considered for allowance or
being adjudicated.
(B)
Claims meeting the following criteria are eligible for
inclusion in the enhanced care program:
(1)
The injured
worker's claim is a work-related knee only injury as documented by the medical
evidence in the claim, and is allowed for knee conditions only;
(2)
The injured
worker's physician of record is certified to participate in the HPP, and has
signed and agrees to comply with the "Enhanced Care Program Provider Addendum"
to the provider certification application and agreement or recertification
application and agreement, in accordance with rule
4123-6-02.3 of the Administrative Code;
and
(3)
The injured worker's employer of record is not:
(b)
A self-insuring employer providing compensation and
benefits pursuant to section
4123.35 of the Revised
Code.
(C)
The operation of
the enhanced care program does not impair in any manner the right of an
employer, injured worker, or their representatives to appeal a claim,
additional allowance, or medical treatment reimbursement determination under
section 4123.511 of the Revised Code or
rule 4123-6-16 of the Administrative
Code. However, if the employer, injured worker, or their representatives
exercises its right to appeal a claim, additional allowance, or medical
treatment reimbursement determination, the claim will be removed from the
enhanced care program.
Notes
Ohio Admin. Code 4123-6-36
Effective:
1/1/2023
Five Year Review (FYR) Dates:
02/01/2027
Promulgated
Under: 119.03
Statutory
Authority: 4121.12,
4121.121,
4123.66
Rule
Amplifies: 4121.12,
4121.121,
4121.441