4123-6-26 Claimant reimbursement.

 

 

 

4123-6-26                    Claimant reimbursement.

 

 

 

When the claimant or any other person making payment on behalf of the claimant, including a volunteer, pays for medical services or supplies directly to a health care provider and the claim or condition is subsequently allowed, the payor shall be reimbursed upon submission of evidence of the receipt and payment for that service or supply. The payor will receive no more than the amount that would have been paid to the health care provider as provided by the rules of this chapter of the Administrative Code. However, in cases where the payor is the claimant's health insurer, if the claimant seeks reimbursement for an out-of-pocket copayment and the claimant's health insurer has already been reimbursed or later seeks reimbursement, the claimant may be reimbursed for the copayment and the claimant's health insurer may be reimbursed up to the amount that would have been paid to the health care provider as provided by the rules of this chapter of the Administrative Code. When payment has been made to the health care provider, the payor shall be informed to seek reimbursement from the provider.

 

The bureau shall inform a claimant or payor whether a health care provider participates in the HPP or QHP.

 

(A)When the claimant or any other person making payment on behalf of the claimant, including a volunteer, pays for medical services or supplies directly to a health care provider and the claim or condition is subsequently allowed, the payor shall be reimbursed upon submission of evidence of the receipt and payment for that service or supply. Except as otherwise provided in paragraphs (A)(1) and (A)(2) of this rule, the payor will receive no more than the amount that would have been paid to the health care provider as provided by the rules of this chapter of the Administrative Code.

 

(1)In cases where the payor is the claimant's health insurer, if the claimant seeks reimbursement for an out-of-pocket copayment, the claimant may be reimbursed for the copayment and the claimant's health insurer may be reimbursed up to the amount that would have been paid to the health care provider as provided by the rules of this chapter of the Administrative Code.

 

(2)In cases where the claimant pays a pharmacy out of pocket for an outpatient medication because the medication is not payable under division (I) of section 4123.511 of the Revised Code on the date of service, if the medication later becomes payable, the claimant may be reimbursed the full amount of the claimant's out-of-pocket payment.

 

(B)When the bureau has already made payment to the health care provider, the payor shall be informed to seek reimbursement from the provider. The bureau  shall inform a claimant or payor whether a health care provider participates in the HPP or QHP.

 

(C)Requests for reimbursement pursuant to this rule shall be subject to the timeframes set  forth  in  division  (B)  of  section  4123.52  of  the  Revised  Code  and  in  rule

 

 

 

4123-3-23 of the Administrative Code.

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, 4121.30, 4121.31, 4121.44, 4121.441,

4123.05, 4123.66

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

Prior Effective Dates:                         2/12/97, 6/24/11