4123-6-25 Payment for medical supplies and services.

 

 

 

4123-6-25                    Payment for medical supplies and services.

 

 

 

(A)     Medical supplies and services will be considered for payment when they are medically necessary for the diagnosis and treatment of conditions allowed in the claim, are causally related to the conditions allowed in the claim, and are rendered by a health care provider. Payment for services rendered to a claimant shall be paid to a health care provider only when the provider physically examines or treats the claimant, has either renders or directly supervises treatment, and certifies the fee bill filed delivered, rendered or directly supervised the examination, treatment, evaluation or any other medically necessary and related services provided to the claimant. By submitting any fee bill to the bureau, in either hardcopy or electronic format, the health care provider affirms that medical supplies and services have been provided to the claimant as required by this rule.

 

(B)   service Services rendered by a health care provider providers is are subject to review for coding requirements outlined in paragraph (B) (C) of this rule. Payment Payments to a health care provider providers may be adjusted based upon these guidelines.

 

(B)(C) Coding systems.

 

(1)   Billing codes.

 

(a)   Providers Practitioners are required to use the most current edition of the health care financing administration's centers for medicare and medicaid services' healthcare common procedure coding system (HCPCS) to indicate the procedure or service rendered to the injured worker workers. Inpatient and outpatient hospital services must be billed using the national uniform billing committee's revenue center codes. Outpatient medication services must be billed using the national drug coding (NDC) system.

 

(b) Inpatient and outpatient hospital services must be billed using the national uniform billing committee's revenue center codes.

 

(c) Outpatient medication services must be billed pursuant to the requirements described in the bureau's provider billing and reimbursement manual.

 

(b)(d) To insure accurate data collection, the bureau shall adopt a standardized coding structure which shall be adopted by any MCO, or QHP, or self-insuring employer.

 

(2)   ICD-9 diagnosis codes.

 

 

 

Providers      must     use     the   most    current    edition     of    the    "International Classification of Diseases, clinical modification" to indicate diagnoses.

(C)(D) Prior to services being delivered, the provider must make reasonable effort to notify the injured worker claimant, bureau, MCO, or QHP or self-insuring employer when the provider has knowledge that the services may not be related to the claimed or allowed condition(s) related to the industrial injury or illness, or that a service is noncovered non-covered. The provider may not knowingly bill or seek payment from the bureau, MCO, QHP or self-insured employer for services that are not related to the claimed or allowed condition(s) related to the industrial injury or illness. The provider may not knowingly mislead or direct providers of ancillary services to bill or seek payment for services that are not related to the claimed or allowed condition.

The provider may not bill or seek payment from the injured worker claimant for services determined as medically unnecessary through the use of bona fide peer review based on accepted treatment guidelines.

Effective:                                                     04/01/2007

R.C. 119.032 review dates:                         08/09/2006 and 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:                                  4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates:                         2/12/97