4123-6-16.2 Medical treatment reimbursement requests.

 

 

 

Rule Summary and Fiscal Analysis (Part A)

 

Bureau of Workers' Compensation

Agency Name

 

Tom Sico

Division                                                                  Contact

 

30 West Spring St. L26 Columbus OH 43215-0000	614-466-6600	614-466-9384
Agency Mailing Address (Plus Zip)	Phone	Fax

 

 

4123-6-16.2

Rule Number

NEW

TYPE of rule filing

Rule Title/Tag Line              Medical treatment reimbursement requests.

RULE SUMMARY

1.  Is the rule being filed consistent with the requirements of the RC 119.032 review? No

2.  Are you proposing this rule as a result of recent legislation? No

3.  Statute prescribing the procedure in accordance with the agency is required to adopt the rule: 119.03

4.  Statute(s) authorizing agency to adopt the rule: 4121.12, 4121.121, 4121.30, 4121.31, 4123.05

5.  Statute(s) the rule, as filed, amplifies or implements: 4121.12, 4121.44, 4121.444, 4123.66

6.  State the reason(s) for proposing (i.e., why are you filing,) this rule:

To adopt a new rule relating to medical reimbursement requests in the Bureau's Health Partnership Program.

7.  If the rule is an AMENDMENT, then summarize the changes and the content of the proposed rule; If the rule type is RESCISSION, NEW or NO CHANGE, then summarize the content of the rule:

This new rule provides that medical treatment reimbursement requests must be

submitted by the physician of record (POR) or treating provider (on form C-9 or equivalent) to the MCO responsible for medical management of the claim prior to the POR or treating provider's initiating any non-emergency treatment, and that such requests shall be evaluated by the MCO using the three-part "Miller" test (the requested services are reasonably related to the injury, the requested services are reasonably necessary for treatment of the injury, and the costs of the services are medically reasonable). The rule clarifies that medical treatment reimbursement requests in inactive claims will be processed in accordance with Ohio Administrative Code 4123-3-15.

The rule also provides that the MCO may dismiss, without prejudice, medical treatment reimbursement requests:

Submitted by providers who are not enrolled with BWC and who refuse to become enrolled, or who are enrolled but non-certified and are ineligible for payment as a non-certified provider under rules 4123-6-06.3 or 4123-6-12 of the Administrative Code or division (J) of section 4121.44 of the Revised Code;

That are not accompanied by supporting medical documentation that the POR or treating provider has seen and examined the injured worker within 30 days prior to the request, or that the injured worker requested a visit with the provider (and such evidence is not provided to the MCO upon request);

That duplicate a previous medical treatment reimbursement request that has been denied in a final administrative or judicial determination where the new request is not accompanied by supporting medical documentation of new and changed circumstances impacting treatment (and such evidence is not provided to the MCO upon request); or

Where the rule states that if the MCO determines before, after or during delivery of services, that any approved medical treatment reimbursement request is not medically indicated or necessary, is not producing the desired outcomes, or the injured worker is not responding, the MCO may notify the parties of its decision to discontinue payment of approved treatment that has not already been rendered. This decision may be appealed through the ADR process.

8.  If the rule incorporates a text or other material by reference and the agency claims the incorporation by reference is exempt from compliance with sections

121.71 to 121.74 of the Revised Code because the text or other material is generally available to persons who reasonably can be expected to be affected by the rule, provide an explanation of how the text or other material is generally available to those persons:

This response left blank because filer specified online that the rule does not incorporate a text or other material by reference.

9.  If the rule incorporates a text or other material by reference, and it was infeasible for the agency to file the text or other material electronically, provide an explanation of why filing the text or other material electronically was infeasible:

This response left blank because filer specified online that the rule does not incorporate a text or other material by reference.

10.  If the rule is being rescinded and incorporates a text or other material by reference, and it was infeasible for the agency to file the text or other material, provide an explanation of why filing the text or other material was infeasible:

Not Applicable.

11.  If revising or refiling this rule, identify changes made from the previously filed version of this rule; if none, please state so:

Not Applicable.

12.  119.032 Rule Review Date:

(If the rule is not exempt and you answered NO to question No. 1, provide the scheduled review date. If you answered YES to No. 1, the review date for this rule is the filing date.)

NOTE: If the rule is not exempt at the time of final filing, two dates are required: the current review date plus a date not to exceed 5 years from the effective date for Amended rules or a date not to exceed 5 years from the review date for No Change rules.

FISCAL ANALYSIS

13.  Estimate the total amount by which this proposed rule would increase / decrease either revenues / expenditures for the agency during the current biennium (in dollars): Explain the net impact of the proposed changes to the budget of your agency/department.

This will have no impact on revenues or expenditures. 0.00

N/A

14.  Identify the appropriation (by line item etc.) that authorizes each expenditure necessitated by the proposed rule:

N/A

15.  Provide a summary of the estimated cost of compliance with the rule to all directly affected persons. When appropriate, please include the source for your information/estimated costs, e.g. industry, CFR, internal/agency:

N/A

16.  Does this rule have a fiscal effect on school districts, counties, townships, or municipal corporations? No

17.  Does this rule deal with environmental protection or contain a component dealing with environmental protection as defined in R. C. 121.39? No