4123-6-04.3. MCO scope of services - MCO medical management and claims management assistance

(A) The MCO shall refer a medical treatment reimbursement request in an inactive claim to the bureau, with the MCO's recommendation, for a determination of both the causal relationship between the original injury and the current incident precipitating the treatment request and the necessity and appropriateness of the requested treatment as provided in rule 4123-3-15 of the Administrative Code.

(B) The MCO, in conjunction with the employer, employee, attending physician, and the bureau claims personnel assigned to the claim, shall provide medical management and cost containment services that provide the injured worker high-quality, cost-effective medical care that focuses on minimizing the physical, emotional, and financial impact of a work-related injury or illness and promotes a safe and timely return to work.

(C) The MCO shall comply with bureau procedures for reporting injuries to the bureau and employers, and shall instruct the provider to forward to the MCO and the bureau, subject to the confidentiality provisions contained in rule 4123-6-15 of the Administrative Code, all necessary data to effectuate medical and claims management.

(D) MCO guidelines may not be more restrictive for a non-panel provider than for an MCO panel provider. An MCO may not create a procedure that restricts an employee's option to change providers.

(E) An MCO shall provide medical management and return to work management services for the life of a claim, as long as the employer remains assigned to the MCO, regardless of the date of injury of the claim. In cases where an employee has multiple claims with different employers, each claim shall remain with the associated employer and shall be managed by that employer's current MCO.

(F) Either the MCO or the bureau may schedule an independent medical examination (IME) of the claimant to assist in the alternative dispute resolution (ADR) process under rule 4123-6-16 of the Administrative Code.

(1) An ADR IME shall be limited to issues relating to medical treatment disputes, and shall not include extent of disability issues. An ADR IME shall not be conducted at the request of an employer and does not substitute for an examination permitted under section 4123.65.1 of the Revised Code.

(2) If an ADR IME is scheduled under this rule, the parties, and their representatives, if any, shall 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 shall be submitted to the claim file. The claimant shall be reimbursed for the claimant's traveling and meal expenses, in a manner and at the rates as established by the bureau from time to time.

(3) If an ADR IME is scheduled under this rule to assist in resolving a medical dispute, the IME and the ADR process shall be completed in accordance with the requirements of rule 4123-6-16 of the Administrative Code.

(4) If a claimant refuses to attend an independent medical examination to assist in the alternative dispute resolution process, the MCO shall refer the issue to the bureau, and the claimant's right to benefits may be suspended during the period of refusal.

Effective: 11/13/2015
Five Year Review (FYR) Dates: 08/26/2015 and 08/25/2020
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
Prior Effective Dates: 2/16/96, 1/1/99, 3/27/00, 1/1/01, 11/1/04, 2/1/10