4123-6-04.4. MCO scope of services - fee bill review and audit process

(A) The MCO shall review all bills submitted to it for payment by a provider consistent with the MCO's previous treatment reimbursement approval/denial of the service billed, the MCO's utilization standards, the criteria set forth in rule 4123-6-25 of the Administrative Code, applicable industry standards, and the requirements of the MCO contract.

(B) The MCO shall have in place and operating a grievance hearing procedure allowing a provider, employer, or employee to grieve a disputed bill payment.

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, 2/1/10

Prior History: (Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 02/01/2015
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4123.05
Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66
Prior Effective Dates: 2/16/96 )