4123-6-04.5 MCO scope of services - bureau claims management.

 

 

 

4123-6-04.5                 MCO scope of services - bureau claims management.

 

 

 

(A)    Upon receipt of notification of a workers' compensation claim, the bureau will determine the compensability of the claim and the allowed conditions of the claim pursuant to the provisions of section 4123.511 of the Revised Code. The bureau will notify all parties and the MCO of the allowed conditions in the claim.

 

(B)    The employer or employee or representative may appeal the bureau's order to the industrial commission pursuant to the provisions of rule 4123-6-16 of the Administrative Code and section 4123.511 of the Revised Code. Upon referral from an MCO, the bureau will determine the causal relationship between the original injury and the current incident precipitating a medical treatment reimbursement request in a 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. The bureau will notify all parties and the MCO of its determination.

 

The employer or employee or representative may appeal the bureau's order to the industrial commission pursuant to section 4123.511 of the Revised Code.

 

(C)   The bureau shall not make medical payments in a disallowed claim or for conditions not allowed in a claim until permitted to do so under the provisions of section

4123.511 of the Revised Code. The bureau shall notify all parties and the MCO when a claim or conditions are allowed or disallowed and indicate whether treatment rendered therefore may or may not be paid.

 

(D)   During the adjudication process, the provider may continue to render or the MCO may continue to manage medical services on behalf of the employee, but the bureau will not pay the MCO for medical services in a disallowed claim or for disallowed conditions. If the claim is disputed the MCO shall notify the claimant that continued treatment may be at the claimant's expense.

 

(E)    The bureau will provide ongoing indemnity and disability claims management on allowed claims.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4123-6-04.5                                                                                                                           2

Effective:

R.C. 119.032 review dates:    03/01/2004

WITHDRAWN ELECTRONICALLY

Certification

01/29/2004

Date

Promulgated Under:	119.03
Statutory Authority:	4121.12, 4121.30, 4121.31,
	4123.05
Rule Amplifies:	4121.121, 4121.44, 4121.441,
	4123.66

Prior Effective Dates: 2/16/96