Ohio Admin. Code 4123-6-01
As used in this chapter:
Notification that a specific treatment, service, or equipment is medically necessary for the diagnosis or treatment of an allowed condition.
A provider who is approved by the bureau for participation in the health partnership program (HPP) pursuant to this chapter of Administrative Code.
A process by which the bureau approves a provider or managed care organization (MCO) for participation in the HPP.
A process by which the bureau validates or reviews the completed and signed application of a provider for certification or recertification.
Procedures for the resolution of medical disputes prior to filing an appeal under section 4123.511 of the Revised Code.
Medical services that are required for the immediate diagnosis and treatment of a condition that, if not immediately diagnosed and treated, could lead to serious physical or mental disability or death, or that are immediately necessary to alleviate severe pain. Emergency treatment includes treatment delivered in response to symptoms that may or may not represent an actual emergency, but is necessary to determine whether an emergency exists.
As used in the rules of this chapter, the term "employee" includes the terms "injured worker" and "claimant" and all employees of employers covered under HPP.
A physician or practitioner, or any person, firm, corporation, limited liability corporation, partnership, association, agency, institution, or other legal entity licensed, certified, or approved by a professional standard-setting body or by medicare or medicaid to provide medical services or supplies to an injured worker, including a qualified vocational rehabilitation provider.
The bureau of workers' compensation's comprehensive managed care program under the direction of the chief of medical services as provided in sections 4121.44 and 4121.441 of the Revised Code.
An institution that provides facilities for surgical and medical diagnosis and treatment of bed patients under the supervision of staff physicians and furnishes twenty-four hour-a-day care by registered nurses.
An injured worker is considered to be an inpatient when he or she has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. An injured worker is considered an inpatient if there is a formal order for admission from the physician. The determination of an inpatient stay is not based upon the number of hours involved. If it later develops during the uninterrupted stay that the injured worker is discharged, transferred to another inpatient unit within the hospital, transferred to another hospital, transferred to another state psychiatric facility or expires and does not actually use a bed overnight, the order from the attending physician addressing the type of encounter will define the status of the stay.
The injured worker is not receiving inpatient care, as "inpatient" is defined in paragraph (J)(1) of this rule, but receives outpatient services at a hospital. An outpatient encounter cannot exceed seventy-two hours of uninterrupted duration.
For the purposes of the rules of this chapter of the Administrative Code only, an injury as defined in division (C) of section 4123.01 of the Revised Code or an occupational disease as defined in division (F) of section 4123.01 of the Revised Code.
A vendor as defined under section 4121.44 of the Revised Code who has contracted with the bureau to provide medical management and cost containment services as provided in sections 4121.44 and 4121.441 of the Revised Code. As used in these rules, a managed care organization is not a health care provider.
Services which are reasonably necessary for the diagnosis or treatment of disease, illness, and injury, and meet accepted guidelines of medical practice. A medically necessary service must be reasonably related to the illness or injury for which it is performed regarding type, intensity, and duration of service and setting of treatment.
The same as drug as defined by division (E) of section 4729.01 of the Revised Code.
A provider who is not approved by the bureau for participation in the HPP, or whose certification has lapsed and has not been reinstated pursuant to rule 4123-6-02.4 of the Administrative Code.
Pursuant to Chapters 4121. and 4123. of the Revised Code, the authorized physician chosen by the employee to direct treatment.
A physician, or a physical therapist, occupational therapist, optometrist, or any other person currently licensed and duly authorized to practice within his or her respective health care field.
A bureau form providers complete that requests background information and documentation necessary for certification and which, if completed and signed by the provider and approved by the bureau, constitutes a written, contractual agreement between the bureau and the provider.
A medical management analysis tool used by the bureau or MCO which at a minimum, utilizes line item detail from a medical bill and employee specific information including, but not limited to, demographics, diagnosis allowances, return to work and remain at work statistics, and other data regarding treatment, to evaluate a health care provider on the basis of cost, utilization and treatment outcomes efficiency and compliance with bureau requirements.
A health care plan sponsored by an employer or a group of employers which meets the standards for qualification under section 4121.442 of the Revised Code and is certified as a qualified health care plan with the bureau.
A bureau form certified providers complete as part of the provider recertification process that requests background information and documentation necessary for recertification and which, if completed and signed by the provider and approved by the bureau, constitutes a written, contractual agreement between the bureau and the provider.
Services to support an injured worker in continued employment where the injured worker is experiencing difficulties performing a job as a result of conditions related to an allowed medical only claim.
Services to support an injured worker in returning to employment where the injured worker is experiencing difficulty as a result of conditions related to an allowed lost time claim.
A work-site program that provides an individualized interim step in the recovery of an injured worker with job restrictions resulting from the allowed conditions in the claim. Developed in conjunction with the employer and the injured worker, or with others as needed, including, but not limited to the collective bargaining agent (where applicable), the physician of record, rehabilitation professionals, and the MCO, a transitional work program assists the injured worker in progressively performing the duties of a targeted job..
Guidelines of medical practice, developed through consensus of practitioner representatives, that assist a practitioner and a patient in making decisions about appropriate health care for specific medical conditions.
A facility where ambulatory care is provided outside a hospital emergency department and is available on a walk in, non-appointment basis.
The assessment of an employee's medical care by the MCO. This assessment typically considers medical necessity, the appropriateness of the place of care, level of care, and the duration, frequency or quality of services provided in relation to the allowed condition being treated.
Ohio Admin. Code 4123-6-01
Five Year Review (FYR) Dates: 1/5/2021 and 08/01/2025
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Prior Effective Dates: 02/16/1996, 09/05/1996, 01/01/1999, 01/01/2001, 03/29/2002, 02/14/2005, 02/01/2010, 11/13/2015