4123-6-16.2 Medical treatment reimbursement requests.

 

 

 

4123-6-16.2                 Medical treatment reimbursement requests.

 

 

 

(A)Medical treatment reimbursement requests must be submitted by the physician of record or eligible treating provider (on form C-9 or equivalent) to the MCO responsible for medical management of the claim prior to initiating any non-emergency treatment.

 

(B)Medical treatment reimbursement requests shall be evaluated by the MCO using the following three-part test (all parts must be met to authorize treatment reimbursement):

 

(1)The requested services are reasonably related to the industrial injury (allowed conditions);

 

(2)The requested services are reasonably necessary for treatment of the industrial injury (allowed conditions);

 

(3) The costs of the services are medically reasonable.

 

(C)Medical treatment reimbursement requests in claims which have not had activity or a request for further action within a period of time in excess of thirteen months shall be processed in accordance with the provisions of rule 4123-3-15 of the Administrative Code.

 

(D)The MCO may dismiss without prejudice medical treatment reimbursement requests submitted by providers who are not enrolled with the bureau 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.

 

(E)The MCO may dismiss without prejudice medical treatment reimbursement requests that are not accompanied by supporting medical documentation that the submitting physician of record or eligible 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 (via form C-9A or equivalent).

 

(F) The MCO may dismiss without prejudice a medical treatment reimbursement request that duplicates 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 a new and change in circumstances impacting treatment, and such evidence is not provided to the MCO upon request (via form C-9A or equivalent).

 

(G)The MCO may dismiss without prejudice a medical treatment reimbursement request when the underlying claim has been settled, and the dates of service requested are on or after the effective date of the settlement. If the medical treatment reimbursement request includes both dates of service on or after the effective date

 

 

of the settlement and dates of services prior to the effective date of the settlement, the MCO may dismiss without prejudice only that portion of the request relating to dates of service on or after the effective date of the settlement.

(H) If the MCO determines 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 shall be subject to medical dispute resolution pursuant to rule 4123-6-16 of the Administrative Code.

Effective:	04/01/2007
R.C. 119.032 review dates:	03/01/2012
CERTIFIED ELECTRONICALLY
Certification
03/19/2007
Date
Promulgated Under:	119.03
Statutory Authority:	4121.12, 4121.121, 4121.30, 4121.31, 4123.05
Rule Amplifies:	4121.12, 4121.44, 4121.444, 4123.66