4123-6-02.3. Provider access to the HPP - provider application and certification criteria

(A) The bureau shall make available to each provider a provider certification application and agreement or recertification application and agreement, as applicable, which shall require the provider to furnish documentation as provided in rule 4123-6-02.2 of the Administrative Code.

(B) The provider application and agreement or recertification application and agreement shall require the provider to make statements that the provider is without impairments that would interfere with the provider's ability to practice or that would jeopardize a patient's health, and a statement that the application is without misrepresentation, misstatement, or omission of a relevant fact or other acts involving dishonesty, fraud, or deceit. The provider shall provide to the bureau any additional documentation requested, and shall permit the bureau to conduct a review of the provider's practice or facility. The provider shall notify the bureau within thirty days of any change in the provider's status regarding any of the credentialing criteria of paragraph (B) or (C) of rule 4123-6-02.2 of the Administrative Code.

(C) The bureau shall review the application and agreement and all documentation submitted by the provider. The bureau may cross-check data with other governmental agencies or licensing bodies. The bureau may refer provider certification and malpractice issues to the bureau's stakeholders health care quality assurance advisory committee for review as provided under rule 4123-6-22 of the Administrative Code.

(D) By signing the provider application and agreement or recertification application and agreement, the provider agrees to, and the bureau may refuse to certify or recertify or may decertify a provider for failure to:

(1) Provide health services that are applicable to a work-related injury, and not to substantially engage in the practice of experimental modalities of treatment.

(2) Acknowledge and treat injured workers in accordance with bureau recognized treatment guidelines.

(3) Acknowledge and treat injured workers in accordance with the vocational rehabilitation hierarchy.

(4) Provide adequate on-call coverage for patients.

(5) Utilize bureau certified providers when making referrals to other providers.

(6) Timely schedule and treat injured workers to facilitate a safe and prompt return to work.

(7) Release information from the national practitioner data bank or the federation of state licensing boards. The bureau may submit a report to the appropriate state licensing board or data bank as required in the event the provider is decertified.

(8) Practice in a managed care environment and adhere to MCO and bureau procedures and requirements concerning provider compliance, outcome measurement data, peer review, quality assurance, utilization review, bill submission, and dispute resolution.

(9) Adhere to the bureau's confidentiality and sensitive data requirements, and use information obtained from the bureau by means of electronic account access for the sole purpose of facilitating treatment and no other purpose, including but not limited to engaging in advertising or solicitation directed to injured workers.

(10) Comply with the workers' compensation statutes and rules and the terms of the provider application and agreement or recertification application and agreement.

(E) Upon review and determination by the bureau that the provider has met bureau credentialing requirements, the bureau shall certify or recertify the provider as a bureau certified provider.

(F) The bureau may enter into an addendum to a physician's provider certification application and agreement or recertification application and agreement, offering appropriate performance incentives to enhance physician proficiency in patient care and navigation of the Ohio workers' compensation system, to physicians who agree to:

(1) Perform enhanced duties as the treatment team leader in the care of injured workers, as set forth in the addendum, and

(2) Enhanced provider outcome measurement.

Effective: 1/1/2018
Five Year Review (FYR) Dates: 8/25/2020
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, 4123.66
Prior Effective Dates: 2/16/96, 1/15/99, 3/29/02, 2/14/05, 2/1/10, 11/13/15