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

 

 

 

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

 

 

 

(A)    The bureau shall determine the compensability of all claims as provided in rule 4123-6-04.5 of the Administrative Code. Upon referral from an MCO, the bureau will determine both the causal relationship between the original injury and the current incident precipitating shall refer a medical treatment reimbursement request and the necessity and appropriateness of the requested treatment in a an inactive claim which has not had activity or a request for further action within a period of time in excess of thirteen months, as provided in rule 4123-3-15 of the Administrative Code, with the MCO's recommendation, to the bureau 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.

 

(B)   The MCO, in conjunction with the employer, employee, attending physician, and the bureau claims personnel assigned to the claim, shall seek a course of medical or rehabilitative treatment that 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)After the claim has been filed, the bureau shall assign a claim number and shall notify the employee, employer and MCO of that claim number.

 

(D)(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.

 

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

 

(F)(E) Except as provided in paragraph (D) of rule 4123-6-04.6 of the Administrative Code, an MCO shall provide medical management and return to work management services for the life of a claim, as long as the employer remains in contract with assigned to the MCO. An MCO shall manage all claims of the employer, 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.

 

(G)(F)  Pursuant  to  divisions  (A)(1),  (A)(5),  and  (A)(9)  of  section  4121.441  of  the Revised Code, an Either the MCO or the bureau may schedule an independent

 

 

medical examination (IME) of the claimant to assist the MCO in the alternative dispute resolution (ADR) process under rule 4123-6-16 of the Administrative Code or in the medical management of a claim with a date of injury prior to October 20, 1993.

(1)   An MCO may obtain only one independent medical examination in a claim with a date of injury prior to October 20, 1993 for the purpose of medical management of the claim. An MCO independent medical examination ADR IME shall be limited to issues relating to the management of medical treatment and medical treatment disputes, and shall not include extent of disability issues. An MCO independent medical examination 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 the MCO schedules a medical examination an ADR IME is scheduled under this rule, the MCO shall promptly inform the bureau and 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. A An electronic copy of the examination ADR IME report shall be submitted to the bureau, the parties and their representatives upon the MCO's receipt of the report from the doctor 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. The MCO shall provide the claimant with a proper form to be completed by the claimant for reimbursement of such expenses. If

(3) If the MCO schedules a medical examination an ADR IME is scheduled under this rule to assist the MCO in resolving a medical dispute, the MCO shall complete the independent medical examination IME and dispute resolution within the ADR process shall be completed in accordance with the time limits established under requirements of rule 4123-6-16 of the Administrative Code.

(3)(4) If a claimant refuses to attend an independent medical examination scheduled by the MCO to assist the MCO in resolving a medical dispute in a claim, as part of the alternative dispute resolution process under rule 4123-6-16 of the Administrative Code, or in a claim with a date of injury prior to October 20, 1993, the MCO shall refer the issue to the bureau.

Effective:                                                     02/01/2010

R.C. 119.032 review dates:                         11/17/2009 and 02/01/2015

CERTIFIED ELECTRONICALLY

Certification

01/22/2010

Date

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, 1/1/99, 3/27/00, 1/1/01, 11/1/04