Section 4123-6-69 - QHP dispute resolution process(A) This rule shall provide time frames and procedures for review of requests for the delivery of medical services and for the resolution of disputes that may arise between an employee and an employer, an employee and a provider, or an employer and a provider. This rule applies to, but is not limited to, reviews of records, medical disputes arising over issues such as, but not limited to, quality assurance, utilization review, a determination that a service provided to an employee is not covered, is covered or is medically unnecessary; or disputes involving individual health care providers.(B) Initial review and decision upon requests for the delivery of medical services that include, but are not limited to, medical treatment, major diagnostic testing, hospitalization, surgery and physical therapy, shall be completed by the QHP. The employee, employer and provider shall be notified verbally of the outcome of the initial review within forty-eight hours of the request. Within seven working days of the verbal notification, the verbal notification shall be committed to writing and mailed to the employee, employer and provider.(C) A QHP shall have a dispute resolution process beyond initial review that includes one independent level of professional review.(D) A QHP dispute resolution process shall be completed and the QHP shall notify the parties to the dispute and their representatives in writing within twenty-one days of the initial written notice of a dispute, unless an extension of time is otherwise agreed to by the parties. If the QHP schedules the injured worker for an independent medical examination for the independent level of professional review, the twenty-one day time frame shall be tolled, and in such cases the QHP shall complete the dispute resolution process within seven days after receipt of the independent medical examination report.(E) The dispute resolution process shall begin upon written notice of the dispute by the party maintaining the dispute to the parties of the dispute. (1) If an individual health care provider eligible to be physician of record would be providing the services requested in the dispute, the independent level of professional review shall consist of a peer review conducted by an individual or individuals licensed pursuant to the same section of the Ohio Revised Code as the health care provider who would be providing the services requested.(2) Notwithstanding paragraph (E)(1) of this rule, if the QHP has already obtained one or more peer reviews during previous disputes involving the same or similar treatment, the QHP may obtain a different perspective review from a licensed physician who falls outside the peer review criteria set forth in thisparagraph.(3) ) If an individual health care provider not eligible to be physician of record would be providing the services requested in the dispute, the independent level of professional review shall consist of a provider review conducted by an individual or individuals eligible to be physician of record whose scope of practice includes the services requested.(4) If the QHP receives a dispute where the requested treatment appears to be the same as or similar to a previous treatment request for which the QHP conducted a professional review, and the previous treatment request was ultimately denied based on the professional review, the QHP may use the previous professional review to satisfy the independent level of professional review requirement of this paragraph.(F) A dispute unresolved by a QHP dispute resolution process may be appealed to the industrial commission pursuant to section 4123.511 of the Revised Code. Parties to a dispute shall exhaust the dispute resolution procedures of this rule prior to filing an appeal under section 4123.511 of the Revised Code.(G) Notwithstanding the requirements set forth in paragraph (F) of this rule, a dispute unresolved by a QHP providing medical management and cost containment services for a state fund employer shall be referred by the QHP to the bureau within seven working days of the final decision rendered within the QHP dispute resolution process. Within fourteen days of receipt of an unresolved medical dispute, the bureau shall conduct an independent review of the unresolved medical dispute received from the QHP and enter a final bureau order pursuant to section 4123.511 of the Revised Code. This order shall be mailed to all parties and may be appealed to the industrial commission pursuant to section 4123.511 of the Revised Code. Parties to a dispute shall exhaust the dispute resolution procedures of this rule prior to filing an appeal under section 4123.511 of the Revised Code.Ohio Admin. Code 4123-6-69
Effective: 8/1/2020
Five Year Review (FYR) Dates: 2/28/2020 and 08/01/2025
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4121.442, 4123.05
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4121.442
Prior Effective Dates: 09/05/1996