4123-6-16.3 Reimbursement of retroactive medical treatment reimbursement requests.

 

 

 

4123-6-16.3                 Reimbursement        of       retroactive        medical                                   treatment reimbursement requests.

 

 

 

(A)     Except as otherwise provided in paragraph (D) of this rule, medical treatment reimbursement requests submitted retroactively to the MCO responsible for medical management of claim by an injured worker's physician of record or eligible treating a provider eligible to submit such requests, without just cause, for non-emergency treatment delivered, rendered, or directly supervised by the physician of record or eligible treating provider shall, if approved, be reimbursed at seventy-five per cent of the applicable fee schedule amount, and the physician of record or treating provider may not balance bill the injured worker for the difference in amount.

 

(B)  For purposes of this rule, "just cause" includes, but is not limited to:

 

(1)  The treatment requested was emergency treatment;

 

(2)    The provider was not aware that services were for a workers' compensation claim;

 

(3)   The provider was non-bureau certified and had no established relationship with the injured worker;

 

(4)     The  provider  was  initially  bureau  certified  within  six  months  prior  to  the treatment request;

 

(5)     The  treatment  requested  was  for  a  pending  claim  allowance  or  additional allowance with the bureau or industrial commission;

 

(6)     The treatment provided was within the bureau's presumptive authorization guidelines, or does not require prior authorization per the bureau's provider billing and reimbursement manual;

 

(7)   The treatment request was submitted retroactively due to bureau or MCO error;

 

(8)   Other documented justification as deemed sufficient by the bureau.

 

(C)   Determinations that an approved medical treatment reimbursement request shall be reimbursed at seventy-five per cent of the applicable fee schedule amount pursuant to paragraph (A) of this rule shall be subject to the grievance hearing procedure for disputed bill payments provided by rule 4123-6-04.4 of the Administrative Code.

 

 

 

 

(D)      Retroactive medical treatment reimbursement requests submitted within seven calendar days of the initiation of treatment or prior to the date of the physician of record or eligible treating provider's next encounter with the injured worker, whichever is earlier, shall not be subject to payment reduction under paragraph (A) of this rule.

Effective:                                                             11/13/2015

Five Year Review (FYR) Dates:                         08/26/2015 and 08/25/2020

CERTIFIED ELECTRONICALLY

Certification

11/02/2015

Date

Promulgated Under:                           119.03

Statutory Authority:                           4121.12, 4121.121, 4121.30, 4121.31, 4121.44,

4121.121, 4123.05, 4123.66

Rule Amplifies:                                  4121.12, 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates:                         1/1/13